Provider Demographics
NPI:1790471746
Name:PURVIS, KELANDA (SPECIALIST)
Entity Type:Individual
Prefix:
First Name:KELANDA
Middle Name:
Last Name:PURVIS
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 YAUPON RD APT B
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-7952
Mailing Address - Country:US
Mailing Address - Phone:254-629-0064
Mailing Address - Fax:
Practice Address - Street 1:2201 W STAN SCHULUTER LOOP
Practice Address - Street 2:SUITE A-400
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549
Practice Address - Country:US
Practice Address - Phone:254-629-0064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1914468174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty