Provider Demographics
NPI:1114203130
Name:MITCHELL, KELLY D (SRNA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:D
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-8806
Mailing Address - Country:US
Mailing Address - Phone:501-310-5461
Mailing Address - Fax:
Practice Address - Street 1:3333 SPRINGHILL DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2922
Practice Address - Country:US
Practice Address - Phone:501-202-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR40164390200000X
ARC002890367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program