Provider Demographics
NPI:1790939460
Name:APPLE, KACEY CHURCHWELL (APRN)
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:CHURCHWELL
Last Name:APPLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 S RIFE MEDICAL LN
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1452
Mailing Address - Country:US
Mailing Address - Phone:479-338-3331
Mailing Address - Fax:479-338-2274
Practice Address - Street 1:2710 S RIFE MEDICAL LN
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1452
Practice Address - Country:US
Practice Address - Phone:479-338-3331
Practice Address - Fax:479-338-2274
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005531363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1790939460Medicaid