=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053275263
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY NUTT APRN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2025
-----------------------------------------------------
Last Update Date | 12/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 THOMPSON AVE STE A
-----------------------------------------------------
City | EL DORADO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71730-4464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-864-8010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2824 HAYNESVILLE HWY
-----------------------------------------------------
City | EL DORADO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71730-9721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-831-1676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 124584
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------