Provider Demographics
NPI:1982703609
Name:CLARDY, PENNY D (APRN)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:D
Last Name:CLARDY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-750-4843
Practice Address - Street 1:350 SALEM RD STE 1
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6166
Practice Address - Country:US
Practice Address - Phone:501-336-8300
Practice Address - Fax:501-329-5508
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003472363LP0808X
ARA03472 ANP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR188517758Medicaid