Provider Demographics
NPI:1124582911
Name:DAVIS, KELLI RENEE (ACNPC-AG)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:RENEE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5650 SLEDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76126-5357
Mailing Address - Country:US
Mailing Address - Phone:325-518-8492
Mailing Address - Fax:
Practice Address - Street 1:3001 SAINT LYNDA DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4857
Practice Address - Country:US
Practice Address - Phone:817-687-9138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139609363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care