Healthcare Provider Details

I. General information

NPI: 1629343868
Provider Name (Legal Business Name): KELLY A TRAYLOR APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SKYLINE DR
RUSSELLVILLE AR
72801-3363
US

IV. Provider business mailing address

101 SKYLINE DRIVE
RUSSELLVILLE AR
72801-3363
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA03661
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: