Provider Demographics
NPI:1972055184
Name:GALLIVAN, KATRINA NICOLE (APRN)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:NICOLE
Last Name:GALLIVAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5315 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1858
Mailing Address - Country:US
Mailing Address - Phone:605-504-3513
Mailing Address - Fax:501-666-3956
Practice Address - Street 1:1501 MILITARY RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2914
Practice Address - Country:US
Practice Address - Phone:501-776-8341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR223712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily