Healthcare Provider Details

I. General information

NPI: 1922278878
Provider Name (Legal Business Name): KELLIE NICHOLE ROBERTSON MSN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE NICHOLE LANG

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3344 N FUTRALL DR
FAYETTEVILLE AR
72703-4057
US

IV. Provider business mailing address

PO BOX 550
LOWELL AR
72745-0550
US

V. Phone/Fax

Practice location:
  • Phone: 479-582-7395
  • Fax: 479-582-7310
Mailing address:
  • Phone: 479-463-7775
  • Fax: 479-463-7187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA03078 ANP
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: