Provider Demographics
NPI:1902064272
Name:EASLEY DOTSON, KELLEY L (APN PNP-BC)
Entity type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:L
Last Name:EASLEY DOTSON
Suffix:
Gender:F
Credentials:APN PNP-BC
Other - Prefix:MS
Other - First Name:KELLEY
Other - Middle Name:L
Other - Last Name:DOTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APN PNP-BC
Mailing Address - Street 1:PO BOX 251418
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72225-1418
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-364-4082
Practice Address - Street 1:1102 CRESTWOOD CIR
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-5513
Practice Address - Country:US
Practice Address - Phone:479-394-7301
Practice Address - Fax:479-394-0371
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA001612363LP2300X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR178404758Medicaid