Provider Demographics
NPI:1356728273
Name:SMITH, KALLIE (ATC, LAT)
Entity type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E HORIZON RD
Mailing Address - Street 2:
Mailing Address - City:WARD
Mailing Address - State:AR
Mailing Address - Zip Code:72176-8608
Mailing Address - Country:US
Mailing Address - Phone:870-613-0870
Mailing Address - Fax:
Practice Address - Street 1:800 FAIR PARK BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1720
Practice Address - Country:US
Practice Address - Phone:501-500-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT6792255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program