Healthcare Provider Details

I. General information

NPI: 1972055184
Provider Name (Legal Business Name): KATRINA NICOLE GALLIVAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATRINA NORMAN

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MILITARY RD
BENTON AR
72015-2914
US

IV. Provider business mailing address

5315 W 12TH ST
LITTLE ROCK AR
72204-1858
US

V. Phone/Fax

Practice location:
  • Phone: 501-776-8341
  • Fax:
Mailing address:
  • Phone: 605-504-3513
  • Fax: 501-666-3956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number223712
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: