Provider Demographics
NPI:1295712776
Name:MCNELLYE-MATTOX, KENDRA L (RN, DFNP-BC)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:L
Last Name:MCNELLYE-MATTOX
Suffix:
Gender:F
Credentials:RN, DFNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8061 ALAMEDA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79915-4705
Mailing Address - Country:US
Mailing Address - Phone:915-351-8972
Mailing Address - Fax:915-351-6033
Practice Address - Street 1:8061 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79915-4705
Practice Address - Country:US
Practice Address - Phone:915-351-8972
Practice Address - Fax:915-351-6033
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP124124363LF0000X
IN71001784A363L00000X
NM02123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000487073OtherBLUE SHIELD
INP00301672OtherRR MEDICARE
NM83625739Medicaid
F1104136OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION #
IN200491110Medicaid
NM83625739Medicaid
Q24550Medicare UPIN
LA35764OtherCDS - CONTROLLED DANGEROUS SUBSTANCE LICENSE
MM1146629OtherDEA - CONTROL SUBSTANCE REGISTRATION