Provider Demographics
NPI:1841370277
Name:CERASUOLO, KELLEY (CPNP)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:CERASUOLO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2316
Mailing Address - Country:US
Mailing Address - Phone:832-822-3555
Mailing Address - Fax:832-825-3308
Practice Address - Street 1:200 BLOSSOM ST
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4204
Practice Address - Country:US
Practice Address - Phone:281-204-1334
Practice Address - Fax:832-632-2670
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX681623363L00000X
TXAP111450363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147339901Medicaid
TX147339901Medicaid
TX86N556Medicare PIN