Provider Demographics
NPI:1033308010
Name:LEE, KELLY (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 E BANKHEAD HWY
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-9558
Mailing Address - Country:US
Mailing Address - Phone:817-594-5880
Mailing Address - Fax:817-595-6850
Practice Address - Street 1:2618 E BANKHEAD HWY
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-9558
Practice Address - Country:US
Practice Address - Phone:817-594-5880
Practice Address - Fax:817-594-6850
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX534915363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX53506Medicare UPIN