Provider Demographics
NPI:1326315359
Name:KELLEY, KRISTIE (RT)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3820 POINTE PKWY
Mailing Address - Street 2:3820 POINTE PARKWAY AT FOLSOM DRIVE, ONE FOLSOM
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-2000
Mailing Address - Country:US
Mailing Address - Phone:409-767-8221
Mailing Address - Fax:
Practice Address - Street 1:3820 POINTE PKWY
Practice Address - Street 2:3820 POINTE PARKWAY AT FOLSOM DRIVE, ONE FOLSOM
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-2000
Practice Address - Country:US
Practice Address - Phone:409-767-8221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15935247100000X
TX2255792471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist