Provider Demographics
NPI:1982186433
Name:KULLENBERG, KELLY (LVN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KULLENBERG
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 PASEO VERDE DR
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-8293
Mailing Address - Country:US
Mailing Address - Phone:512-426-3515
Mailing Address - Fax:
Practice Address - Street 1:3508 FAR WEST BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3080
Practice Address - Country:US
Practice Address - Phone:512-828-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX149133164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse