Healthcare Provider Details

I. General information

NPI: 1730135922
Provider Name (Legal Business Name): KELLY ANN LUEDERS DMS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ANN ELLIOTT PA-C

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 NE LEGACY PKWY
BENTONVILLE AR
72712-4940
US

IV. Provider business mailing address

1303 NE LEGACY PKWY
BENTONVILLE AR
72712-4940
US

V. Phone/Fax

Practice location:
  • Phone: 479-271-2387
  • Fax: 479-202-4840
Mailing address:
  • Phone: 501-337-9031
  • Fax: 479-202-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-443
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1191
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2009009834
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-443
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: