Provider Demographics
NPI:1891155222
Name:HARRIS, KELLY (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 675205
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-5205
Mailing Address - Country:US
Mailing Address - Phone:501-224-1690
Mailing Address - Fax:
Practice Address - Street 1:10301 KANIS RD STE 1
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6205
Practice Address - Country:US
Practice Address - Phone:501-562-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004650363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily