Provider Demographics
NPI:1659173094
Name:KELLY, SHAQUITA
Entity type:Individual
Prefix:
First Name:SHAQUITA
Middle Name:
Last Name:KELLY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 OAKHURST SCENIC DR APT 2462
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-2087
Mailing Address - Country:US
Mailing Address - Phone:318-418-4415
Mailing Address - Fax:
Practice Address - Street 1:61 N KEGLEY RD
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-4067
Practice Address - Country:US
Practice Address - Phone:254-899-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16257111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor