Healthcare Provider Details

I. General information

NPI: 1386548337
Provider Name (Legal Business Name): KYLIE LANDRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 MAIN DR
FAYETTEVILLE AR
72704-5292
US

IV. Provider business mailing address

411 NW PALOMINO ST
BENTONVILLE AR
72712-6474
US

V. Phone/Fax

Practice location:
  • Phone: 918-373-1006
  • Fax:
Mailing address:
  • Phone: 918-373-1006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-312735
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: