Provider Demographics
NPI:1275687964
Name:KELLY, KATHERINE CASEY (NNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:CASEY
Last Name:KELLY
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 301173
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75303-1173
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST
Practice Address - Street 2:500
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3000
Practice Address - Country:US
Practice Address - Phone:832-325-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX533772363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y1419OtherBCBS
TX8Y1419OtherBCBS