Provider Demographics
NPI:1720188295
Name:FENIMORE-GONZALES, KELLY AILEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:AILEEN
Last Name:FENIMORE-GONZALES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5207 HERITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034
Mailing Address - Country:US
Mailing Address - Phone:817-355-8000
Mailing Address - Fax:817-391-1070
Practice Address - Street 1:5207 HERITAGE AVE
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034
Practice Address - Country:US
Practice Address - Phone:817-355-8000
Practice Address - Fax:817-391-1070
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02796363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical