Provider Demographics
NPI:1477187185
Name:BAJAJ, KELLY POTTER
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:POTTER
Last Name:BAJAJ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 CHERRY TREE DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-8240
Mailing Address - Country:US
Mailing Address - Phone:817-403-3059
Mailing Address - Fax:
Practice Address - Street 1:3301 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2908
Practice Address - Country:US
Practice Address - Phone:682-509-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1477187185363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal