Provider Demographics
NPI:1629343868
Name:TRAYLOR, KELLY A (APN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:TRAYLOR
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SKYLINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3363
Mailing Address - Country:US
Mailing Address - Phone:479-968-2345
Mailing Address - Fax:479-890-2467
Practice Address - Street 1:101 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3363
Practice Address - Country:US
Practice Address - Phone:479-968-2345
Practice Address - Fax:479-890-2467
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03661363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR191897758Medicaid
AR191897758Medicaid