Provider Demographics
NPI:1205121548
Name:BOCK, KELLY MELISSA (NP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MELISSA
Last Name:BOCK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 W ROUND BUNCH RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77611-2434
Mailing Address - Country:US
Mailing Address - Phone:409-735-7305
Mailing Address - Fax:409-735-3371
Practice Address - Street 1:615 W ROUND BUNCH RD
Practice Address - Street 2:
Practice Address - City:BRIDGE CITY
Practice Address - State:TX
Practice Address - Zip Code:77611-2434
Practice Address - Country:US
Practice Address - Phone:409-735-7305
Practice Address - Fax:409-735-3371
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX670013363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX670013OtherNURSING LICENSE
TXF0511108OtherNURSE PRACTITIONER CERTIFICATION