Provider Demographics
NPI:1740762905
Name:SIVAGE, KALLY MARIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:KALLY
Middle Name:MARIE ELIZABETH
Last Name:SIVAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 DARTMOUTH LN
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8200
Mailing Address - Country:US
Mailing Address - Phone:479-561-9583
Mailing Address - Fax:
Practice Address - Street 1:10301 MAYO DR
Practice Address - Street 2:
Practice Address - City:BARLING
Practice Address - State:AR
Practice Address - Zip Code:72923-1660
Practice Address - Country:US
Practice Address - Phone:479-494-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005843363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health