Healthcare Provider Details

I. General information

NPI: 1457494205
Provider Name (Legal Business Name): MRS. KELLI CRAMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 REDMOND RD
JACKSONVILLE AR
72076
US

IV. Provider business mailing address

2520 W MAIN ST
JACKSONVILLE AR
72076
US

V. Phone/Fax

Practice location:
  • Phone: 501-834-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP#1560
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: