Basic Information
| Provider Information | |||||||||
| NPI: | 1780990408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUBBARD | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUBBARD | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | RATCLIFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729510130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796355300 | ||||||||
| FaxNumber: | 4796352010 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 S DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | LAVACA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729414129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792797700 | ||||||||
| FaxNumber: | 4792797701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2010 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AO3428 ANP | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200305120A | 05 | OK | MEDICAID | 186319758 | 05 | AR | MEDICAID |