Provider Demographics
NPI:1922012293
Name:HAUCK, KELLY J (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:HAUCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:BERGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:1500 CITYWEST BLVD
Practice Address - Street 2:STE. 300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:713-458-4229
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP114586367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187247501Medicaid
TX85812UOtherBLUE CROSS
LA1802484OtherLOUISIANA MEDICAID
TXP00355351OtherRAILROAD MEDICARE
TX187247501Medicaid