Healthcare Provider Details

I. General information

NPI: 1770358780
Provider Name (Legal Business Name): MIKAYLA LAUREN BALLARD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8924 KANIS RD
LITTLE ROCK AR
72205-6414
US

IV. Provider business mailing address

PO BOX 497
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 501-455-2712
  • Fax: 501-455-2781
Mailing address:
  • Phone: 870-347-2534
  • Fax: 870-301-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number226569
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: