Provider Demographics
NPI:1356848899
Name:KELLY, TRICIA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 BERKELEY DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-8220
Mailing Address - Country:US
Mailing Address - Phone:817-905-6050
Mailing Address - Fax:
Practice Address - Street 1:1325 PENNSYLVANIA AVENUE SUITE 560
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-820-2890
Practice Address - Fax:817-810-0725
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX821766363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner