Provider Demographics
NPI:1336534411
Name:CARMICAL, KATELYN HALIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATELYN
Middle Name:HALIE
Last Name:CARMICAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATELYN
Other - Middle Name:HALIE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:906 ROBERTS DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-5724
Mailing Address - Country:US
Mailing Address - Phone:870-367-6867
Mailing Address - Fax:870-367-1461
Practice Address - Street 1:906 ROBERTS DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5724
Practice Address - Country:US
Practice Address - Phone:870-367-6867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE12164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program