Provider Demographics
NPI:1962627976
Name:PIERCE, KELLY A (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:PIERCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1523
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1523
Mailing Address - Country:US
Mailing Address - Phone:479-571-6038
Mailing Address - Fax:479-582-0222
Practice Address - Street 1:55 W SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1825
Practice Address - Country:US
Practice Address - Phone:479-442-6266
Practice Address - Fax:479-521-3877
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-62652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5H722OtherAR BC/BS
AR182849001Medicaid
AR5H722OtherAR BC/BS
AR5AD19C912Medicare PIN