Healthcare Provider Details

I. General information

NPI: 1104066299
Provider Name (Legal Business Name): KIMBERLY R ELLIS LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY R DAUGHERTY

II. Dates (important events)

Enumeration Date: 03/02/2009
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 CARPENTER DAM RD STE B
HOT SPRINGS AR
71901-8282
US

IV. Provider business mailing address

201 S ROSE ST
SHERIDAN AR
72150-2451
US

V. Phone/Fax

Practice location:
  • Phone: 501-781-2230
  • Fax: 888-816-7916
Mailing address:
  • Phone: 870-917-2171
  • Fax: 870-917-2161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA0909102
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: