Provider Demographics
NPI:1487063897
Name:KRAUSE, KELLY MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:KRAUSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:JANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:P.O. BOX 763
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654
Mailing Address - Country:US
Mailing Address - Phone:870-425-5464
Mailing Address - Fax:870-425-5465
Practice Address - Street 1:2062 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-7656
Practice Address - Country:US
Practice Address - Phone:870-425-5464
Practice Address - Fax:870-425-5465
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-567363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical