Provider Demographics
NPI:1548749245
Name:WHALEY, KELLY DON
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DON
Last Name:WHALEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0711
Mailing Address - Country:US
Mailing Address - Phone:903-791-9355
Mailing Address - Fax:903-831-7258
Practice Address - Street 1:5220 SE LOOP 286
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460
Practice Address - Country:US
Practice Address - Phone:903-401-8349
Practice Address - Fax:903-680-8050
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138972363LF0000X, 363L00000X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program