Provider Demographics
NPI:1265823843
Name:ELLISON, KELLY ANNE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:ELLISON
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 1:125 DAVIS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-8209
Mailing Address - Country:US
Mailing Address - Phone:682-212-9104
Mailing Address - Fax:
Practice Address - Street 1:125 DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-8209
Practice Address - Country:US
Practice Address - Phone:682-212-9104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127337363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TXPENDINGOtherBCBS
TXPENDINGMedicaid