Provider Demographics
NPI:1164889002
Name:HILL, KERRY RENEE
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:RENEE
Last Name:HILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 TANNER ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72104-2023
Mailing Address - Country:US
Mailing Address - Phone:501-337-9994
Mailing Address - Fax:501-601-1107
Practice Address - Street 1:1580 TANNER ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:AR
Practice Address - Zip Code:72104-2023
Practice Address - Country:US
Practice Address - Phone:501-337-9994
Practice Address - Fax:501-601-1107
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004627363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR214947758Medicaid