Provider Demographics
NPI:1487004461
Name:CHACANACA, KELLIE ANN (APRN)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:CHACANACA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 S THOMPSON ST STE 214
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:479-223-5365
Practice Address - Street 1:5100 S THOMPSON ST STE 214
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6941
Practice Address - Country:US
Practice Address - Phone:479-329-1194
Practice Address - Fax:479-223-5365
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004753363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR214849758Medicaid