Provider Demographics
NPI:1760521777
Name:SCALLY, NICOLE M (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SCALLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S PROMENADE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-9073
Mailing Address - Country:US
Mailing Address - Phone:479-282-2737
Mailing Address - Fax:479-316-4072
Practice Address - Street 1:2000 S PROMENADE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-9073
Practice Address - Country:US
Practice Address - Phone:479-282-2737
Practice Address - Fax:479-316-4072
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM2005-0737207Q00000X
ARE-5959207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR176772001Medicaid
AR454641ZRZFMedicare PIN
AR176772001Medicaid