=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659140309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSI FREDERICK CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2023
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 CHILDRENS WAY # 653
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72202-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-364-1100
-----------------------------------------------------
Fax | 501-364-4082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3525 WESTERN GALES DR
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72405-9197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-803-2079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 121586
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------