Provider Demographics
NPI:1932137155
Name:COUCH, KELLY DIANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:DIANN
Last Name:COUCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:DIANN
Other - Last Name:RAMSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:502 ANCHORAGE LN
Mailing Address - Street 2:HOUSTON
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-2547
Mailing Address - Country:US
Mailing Address - Phone:214-392-6518
Mailing Address - Fax:
Practice Address - Street 1:1635 NORTH LOOP W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1532
Practice Address - Country:US
Practice Address - Phone:626-857-3170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17803363A00000X
TXPA02547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPA17803Medicaid
S90933Medicare UPIN