Provider Demographics
NPI:1245707090
Name:KING, KELLIE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:MCGRUE HAWTHORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2925 BRIARPARK DR STE 575
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-3776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5211 FM 2920 RD STE 101
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77388-3004
Practice Address - Country:US
Practice Address - Phone:281-783-8162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2072363A00000X
TXPA15260363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant