Provider Demographics
NPI:1073909875
Name:KELLY, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SADDLE CLUB RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76088-7622
Mailing Address - Country:US
Mailing Address - Phone:817-965-4905
Mailing Address - Fax:469-916-6740
Practice Address - Street 1:119 SADDLE CLUB RD
Practice Address - Street 2:SUITE B
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76088-7622
Practice Address - Country:US
Practice Address - Phone:817-965-4905
Practice Address - Fax:469-916-6740
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6013243747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant