Provider Demographics
NPI:1811470974
Name:KELLEY, CAROLYN SUE (APRN)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SUE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19002 BUG SCUFFLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST FORK
Mailing Address - State:AR
Mailing Address - Zip Code:72774-2878
Mailing Address - Country:US
Mailing Address - Phone:479-761-0171
Mailing Address - Fax:
Practice Address - Street 1:19002 BUG SCUFFLE RD
Practice Address - Street 2:
Practice Address - City:WEST FORK
Practice Address - State:AR
Practice Address - Zip Code:72774-2878
Practice Address - Country:US
Practice Address - Phone:479-761-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005921363LF0000X
ARR089667163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse