Provider Demographics
NPI:1558604819
Name:GERVAIS, ISABELL KESARI (MBBS, HMD, OMD, NMD)
Entity Type:Individual
Prefix:DR
First Name:ISABELL
Middle Name:KESARI
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:MBBS, HMD, OMD, NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 N FRONTAGE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5001
Mailing Address - Country:US
Mailing Address - Phone:479-249-8200
Mailing Address - Fax:479-249-8201
Practice Address - Street 1:4210 N FRONTAGE RD
Practice Address - Street 2:SUITE B
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5001
Practice Address - Country:US
Practice Address - Phone:479-249-8200
Practice Address - Fax:479-249-8201
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1640132700000X, 175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No132700000XDietary & Nutritional Service ProvidersDietary Manager
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1558604819Medicaid
AR1558604819Medicare NSC
AR1558604819Medicare PIN
AR1558604819Medicaid