Provider Demographics
NPI:1619115649
Name:GLISSON, KELLIE LYNN JR (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:LYNN
Last Name:GLISSON
Suffix:JR
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 HUNTERSCOVE DR
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-8071
Mailing Address - Country:US
Mailing Address - Phone:501-760-2511
Mailing Address - Fax:
Practice Address - Street 1:2410 PINE ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4335
Practice Address - Country:US
Practice Address - Phone:870-245-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL42812164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse