Provider Demographics
NPI:1568002129
Name:ELLISON, KELSEY LYNN
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:ELLISON
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 1:8085 ATLAS PEAR DR APT 824
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77807-1418
Mailing Address - Country:US
Mailing Address - Phone:806-543-8168
Mailing Address - Fax:
Practice Address - Street 1:2801 FRANCISCAN DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2544
Practice Address - Country:US
Practice Address - Phone:979-776-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX882697163W00000X
TX32276363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse