Healthcare Provider Details

I. General information

NPI: 1467835611
Provider Name (Legal Business Name): KEENA MELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SKYLINE DR
RUSSELLVILLE AR
72801-3363
US

IV. Provider business mailing address

101 SKYLINE DR
RUSSELLVILLE AR
72801-3395
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-2345
  • Fax:
Mailing address:
  • Phone: 479-968-2345
  • Fax: 479-890-2467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR093441
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA005952
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: