Provider Demographics
NPI:1821526146
Name:HODGE, KELLY DENISE (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DENISE
Last Name:HODGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 WALDRONS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:HALLSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75650-7680
Mailing Address - Country:US
Mailing Address - Phone:903-238-6353
Mailing Address - Fax:
Practice Address - Street 1:103 W LOOP 281 STE 474
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-4603
Practice Address - Country:US
Practice Address - Phone:903-871-0455
Practice Address - Fax:877-541-7468
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134276363LG0600X, 363LA2100X, 363L00000X, 363LF0000X
TXPENDING363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner