Provider Demographics
NPI:1780990408
Name:HUBBARD, KELLY JO (APN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:HUBBARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-0130
Mailing Address - Country:US
Mailing Address - Phone:479-635-5300
Mailing Address - Fax:479-635-2010
Practice Address - Street 1:603 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:LAVACA
Practice Address - State:AR
Practice Address - Zip Code:72941-4129
Practice Address - Country:US
Practice Address - Phone:479-279-7700
Practice Address - Fax:479-279-7701
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAO3428 ANP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200305120AMedicaid
AR186319758Medicaid
AR186319758Medicaid