Provider Demographics
NPI:1639798572
Name:HOOVER, KALLIE ALYCE (PA-C)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:ALYCE
Last Name:HOOVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4196 HIGHWAY 62 412 STE A
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:870-856-2107
Practice Address - Street 1:106 HIGHWAY 62 W # 412
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576-8059
Practice Address - Country:US
Practice Address - Phone:870-895-2015
Practice Address - Fax:870-895-2164
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT-2020-029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant