Basic Information
Provider Information | |||||||||
NPI: | 1922278878 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTSON | ||||||||
FirstName: | KELLIE | ||||||||
MiddleName: | NICHOLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSN, NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LANG | ||||||||
OtherFirstName: | KELLIE | ||||||||
OtherMiddleName: | NICHOLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 550 | ||||||||
Address2: |   | ||||||||
City: | LOWELL | ||||||||
State: | AR | ||||||||
PostalCode: | 727450550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794637775 | ||||||||
FaxNumber: | 4794637187 | ||||||||
Practice Location | |||||||||
Address1: | 3344 N FUTRALL DR | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727034057 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4795827395 | ||||||||
FaxNumber: | 4795827310 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2008 | ||||||||
LastUpdateDate: | 11/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A03078 ANP | AR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 200241820A | 05 | OK |   | MEDICAID | 175580758 | 05 | AR |   | MEDICAID | 5A990 | 01 | AR | AR BCBS | OTHER | 5A990 | 01 | AR | MEDICARE | OTHER |