Provider Demographics
NPI:1992186597
Name:LEWIS, KELLY FULLER (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:FULLER
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3041 CHURCHILL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-5906
Mailing Address - Country:US
Mailing Address - Phone:972-691-1240
Mailing Address - Fax:972-691-2073
Practice Address - Street 1:3041 CHURCHILL DR STE 300
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022
Practice Address - Country:US
Practice Address - Phone:972-691-1240
Practice Address - Fax:972-691-2073
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXR7519208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics