Provider Demographics
NPI:1407820624
Name:BOULDEN, KELLY DAVENPORT (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DAVENPORT
Last Name:BOULDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4521 S HULEN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4948
Mailing Address - Country:US
Mailing Address - Phone:817-924-5252
Mailing Address - Fax:817-924-6060
Practice Address - Street 1:4521 S HULEN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4948
Practice Address - Country:US
Practice Address - Phone:817-924-5252
Practice Address - Fax:817-924-6060
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL4258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine