Provider Demographics
NPI:1588231146
Name:KOVACH, KELLI (RN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:KOVACH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2188 US HIGHWAY 64
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-9675
Mailing Address - Country:US
Mailing Address - Phone:901-626-2934
Mailing Address - Fax:
Practice Address - Street 1:413 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4149
Practice Address - Country:US
Practice Address - Phone:870-735-2737
Practice Address - Fax:870-551-3724
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR088245163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse