Provider Demographics
NPI:1861000648
Name:WHIDDON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WHIDDON
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 1:330 COUNTY ROAD 2150
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75783-6156
Mailing Address - Country:US
Mailing Address - Phone:903-497-2855
Mailing Address - Fax:
Practice Address - Street 1:330 COUNTY ROAD 2150
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783-6156
Practice Address - Country:US
Practice Address - Phone:903-497-2855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX689557163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse