Provider Demographics
NPI:1073622858
Name:ELLIS, KELLEY D (RNFA, CNOR)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:D
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RNFA, CNOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MISTLETOE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4049
Mailing Address - Country:US
Mailing Address - Phone:817-878-5333
Mailing Address - Fax:817-878-5334
Practice Address - Street 1:1900 MISTLETOE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4049
Practice Address - Country:US
Practice Address - Phone:817-878-5333
Practice Address - Fax:817-878-5334
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX551667163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89N921OtherBCBS OF TX
TX0672032OtherCIGNA
TX7521427OtherAETNA