Provider Demographics
NPI:1871036327
Name:WOHLGEMUTH, KELLI REYNOLDS (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:REYNOLDS
Last Name:WOHLGEMUTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:9200 PINECROFT DR STE 255
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3286
Mailing Address - Country:US
Mailing Address - Phone:281-419-8400
Mailing Address - Fax:281-292-1972
Practice Address - Street 1:9200 PINECROFT DR STE 255
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-3286
Practice Address - Country:US
Practice Address - Phone:281-419-8400
Practice Address - Fax:281-292-1972
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132422363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX389575701Medicaid
TX8KC750OtherBCBS TX