Provider Demographics
NPI:1376928432
Name:RAPPEPORT, KELLY CALLAN (PD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CALLAN
Last Name:RAPPEPORT
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 JENNY LIND RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-7435
Mailing Address - Country:US
Mailing Address - Phone:479-646-2971
Mailing Address - Fax:479-646-8464
Practice Address - Street 1:5701 JENNY LIND RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-7435
Practice Address - Country:US
Practice Address - Phone:479-646-2971
Practice Address - Fax:479-646-8464
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist