Provider Demographics
NPI:1942733589
Name:HALE, KELLY (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HALE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9557 N BEACH ST
Mailing Address - Street 2:STE 121
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6395
Mailing Address - Country:US
Mailing Address - Phone:817-741-5050
Mailing Address - Fax:817-741-5059
Practice Address - Street 1:9557 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6395
Practice Address - Country:US
Practice Address - Phone:817-741-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363LF0000XMedicare UPIN