Provider Demographics
NPI:1831709161
Name:KOMECHAK, KELSEY ANN (NP-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANN
Last Name:KOMECHAK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 679
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:TX
Mailing Address - Zip Code:79510-0679
Mailing Address - Country:US
Mailing Address - Phone:325-893-4010
Mailing Address - Fax:325-893-4035
Practice Address - Street 1:2802 W WALKER ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:TX
Practice Address - Zip Code:76424-4000
Practice Address - Country:US
Practice Address - Phone:254-559-7215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-02
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144537363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily