Basic Information
| Provider Information | |||||||||
| NPI: | 1144836909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHADDY | ||||||||
| FirstName: | KASILYNN | ||||||||
| MiddleName: | ALESE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 W SUNSET AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727624950 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 W SUNSET AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727624950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797177089 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2020 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 125710 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.