Provider Demographics
NPI:1396366613
Name:BURROUGHS, KELLIE NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:NICOLE
Last Name:BURROUGHS
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 1:420 W SLAUGHTER LN APT 1033
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-1756
Mailing Address - Country:US
Mailing Address - Phone:410-829-8804
Mailing Address - Fax:
Practice Address - Street 1:2027 S 61ST ST STE 107
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-6856
Practice Address - Country:US
Practice Address - Phone:254-228-5284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145721363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty