Provider Demographics
NPI:1679314132
Name:YOUNG, NINA R
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 LAUGHRUN DR
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-2030
Mailing Address - Country:US
Mailing Address - Phone:870-270-9238
Mailing Address - Fax:
Practice Address - Street 1:303 LAUGHRUN DR
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2030
Practice Address - Country:US
Practice Address - Phone:870-270-9238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1429839171WV0202X
171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications