Healthcare Provider Details

I. General information

NPI: 1760521777
Provider Name (Legal Business Name): NICOLE M. SCALLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 S PROMENADE BLVD SUITE 202
ROGERS AR
72758-9073
US

IV. Provider business mailing address

2000 S PROMENADE BLVD SUITE 202
ROGERS AR
72758-9073
US

V. Phone/Fax

Practice location:
  • Phone: 479-282-2737
  • Fax: 479-316-4072
Mailing address:
  • Phone: 479-282-2737
  • Fax: 479-316-4072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2005-0737
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-5959
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberE-5959
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: