Provider Demographics
NPI:1265727960
Name:KELLY, PEGGY ANN (APN)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3528
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913-3528
Mailing Address - Country:US
Mailing Address - Phone:479-274-2000
Mailing Address - Fax:
Practice Address - Street 1:7800 DALLAS ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4278
Practice Address - Country:US
Practice Address - Phone:479-259-9286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03551363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner