Healthcare Provider Details

I. General information

NPI: 1861077109
Provider Name (Legal Business Name): KATHERINE GRACE ROSS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 E APPLEBY RD STE 202
FAYETTEVILLE AR
72703-3158
US

IV. Provider business mailing address

616 E 7TH ST APT 6
LITTLE ROCK AR
72202-2544
US

V. Phone/Fax

Practice location:
  • Phone: 479-404-1140
  • Fax: 479-404-1141
Mailing address:
  • Phone: 501-317-5572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-958
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: