Provider Demographics
NPI:1164193868
Name:KELLY, DIANA L (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 HUNTERS GLEN RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-5016
Mailing Address - Country:US
Mailing Address - Phone:325-949-5722
Mailing Address - Fax:
Practice Address - Street 1:1636 HUNTERS GLEN RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-5008
Practice Address - Country:US
Practice Address - Phone:325-949-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1033066363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health