Healthcare Provider Details

I. General information

NPI: 1487004461
Provider Name (Legal Business Name): KELLIE ANN CHACANACA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3623 JOHNSON MILL BLVD STE 101
SPRINGDALE AR
72762-6412
US

IV. Provider business mailing address

8300 LA SCALA AVE
SPRINGDALE AR
72762-4278
US

V. Phone/Fax

Practice location:
  • Phone: 479-575-9359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA004753
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: