Provider Demographics
NPI:1316554264
Name:KING, KELLIE RUTH (APRN)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:RUTH
Last Name:KING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5605 N MACARTHUR BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2693
Mailing Address - Country:US
Mailing Address - Phone:469-400-4784
Mailing Address - Fax:
Practice Address - Street 1:5937 DONNELLY AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5811
Practice Address - Country:US
Practice Address - Phone:682-212-9140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11009343363LF0000X
TX1017997363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily