Provider Demographics
NPI:1619069184
Name:WHITEHEAD, KELLI D (NP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:D
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 N GOLIAD ST
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-7317
Mailing Address - Country:US
Mailing Address - Phone:972-722-4706
Mailing Address - Fax:
Practice Address - Street 1:2004 N GOLIAD ST
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-7317
Practice Address - Country:US
Practice Address - Phone:972-722-4706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP113566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168800404Medicaid
TX168800403Medicaid
TX8K9311Medicare PIN
TX168800403Medicaid
TX8L5679Medicare PIN
TX8G5061Medicare PIN