Provider Demographics
NPI:1376755413
Name:DAVIS, KELLY ANNE (BS DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANNE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:BS DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 TIGER BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712
Mailing Address - Country:US
Mailing Address - Phone:479-271-4438
Mailing Address - Fax:479-271-4438
Practice Address - Street 1:808 TIGER BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712
Practice Address - Country:US
Practice Address - Phone:479-271-4438
Practice Address - Fax:479-271-4438
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004002392111N00000X
AR1637111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y064OtherBCBS
AR156021718Medicaid
P00166048OtherRR MEDICARE
AR5Y064OtherBCBS