Provider Demographics
NPI:1215585237
Name:BODELL, KELSEY ELIZABETH
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:ELIZABETH
Last Name:BODELL
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 1:5310 HARVEST HILL RD STE 290
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-5826
Mailing Address - Country:US
Mailing Address - Phone:214-420-0650
Mailing Address - Fax:
Practice Address - Street 1:1367 DOMINION PLZ
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1013
Practice Address - Country:US
Practice Address - Phone:903-618-2326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA13347363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program