Provider Demographics
NPI:1205011053
Name:KELLEY, KATHRYN L (ACUTE CARE NURSE PRA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:KELLEY
Suffix:
Gender:F
Credentials:ACUTE CARE NURSE PRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17201 I H 45 S
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3311
Mailing Address - Country:US
Mailing Address - Phone:936-270-2099
Mailing Address - Fax:
Practice Address - Street 1:17201 I H 45 S
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-3311
Practice Address - Country:US
Practice Address - Phone:936-270-2099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651221363LA2100X
TXAP114087363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care