Provider Demographics
NPI:1518921006
Name:SKELLEY, KIMBERLY (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SKELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 AUTUMN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3737
Mailing Address - Country:US
Mailing Address - Phone:501-224-5437
Mailing Address - Fax:501-224-3473
Practice Address - Street 1:904 AUTUMN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3737
Practice Address - Country:US
Practice Address - Phone:501-224-5437
Practice Address - Fax:501-224-3473
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3250208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146056001Medicaid
AR02110036900OtherQUALCHOICE
AR7117355OtherAETNA
AR535967OtherHEALTHLINK
AR02110036900OtherQUALCHOICE
AR146056001Medicaid