Provider Demographics
NPI:1356430060
Name:PERSONS, KELLY MARLENE (CRNFA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARLENE
Last Name:PERSONS
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8849 RANDOM ROAD
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179
Mailing Address - Country:US
Mailing Address - Phone:817-236-4276
Mailing Address - Fax:
Practice Address - Street 1:1604 HOSPITAL PARKWAY
Practice Address - Street 2:SUITE 402
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022
Practice Address - Country:US
Practice Address - Phone:817-399-1622
Practice Address - Fax:817-540-0843
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX254126163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant