Provider Demographics
NPI:1174891808
Name:FULL POTENTIAL
Entity type:Organization
Organization Name:FULL POTENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANISHIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:501-442-3268
Mailing Address - Street 1:P.O. BOX 244
Mailing Address - Street 2:
Mailing Address - City:MABELVALE
Mailing Address - State:AR
Mailing Address - Zip Code:72103
Mailing Address - Country:US
Mailing Address - Phone:501-442-3268
Mailing Address - Fax:
Practice Address - Street 1:8109 INTERSTATE 30
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209
Practice Address - Country:US
Practice Address - Phone:501-442-3268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL466563140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric