Provider Demographics
NPI:1467966697
Name:FUSSELL, KELLY RAYE (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RAYE
Last Name:FUSSELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RAYE
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5409
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79608-5409
Mailing Address - Country:US
Mailing Address - Phone:325-437-8655
Mailing Address - Fax:325-437-8647
Practice Address - Street 1:1665 ANTILLEY RD STE 120
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606
Practice Address - Country:US
Practice Address - Phone:325-437-8680
Practice Address - Fax:325-793-5378
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily