Provider Demographics
NPI:1922278878
Name:ROBERTSON, KELLIE NICHOLE (MSN, NP-C)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:NICHOLE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:NICHOLE
Other - Last Name:LANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0550
Mailing Address - Country:US
Mailing Address - Phone:479-463-7775
Mailing Address - Fax:479-463-7187
Practice Address - Street 1:3344 N FUTRALL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4057
Practice Address - Country:US
Practice Address - Phone:479-582-7395
Practice Address - Fax:479-582-7310
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03078 ANP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200241820AMedicaid
AR175580758Medicaid
AR5A990OtherAR BCBS
AR5A990OtherMEDICARE
AR5A990OtherMEDICARE