MEDICARE: KELLI CRISP RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	728510	TX

General Provider Information

NPI Number	:	1023677382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI CRISP RN

Provider Business Mailing Address
First Line	:	4015 I 45 N STE 220
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-5076
Country	:	US
Telephone Number	:	936-441-1122
Fax Number	:	936-494-4440

Provider Business Practice Location Address
First Line	:	804 W MONTGOMERY ST
Second Line	:
City	:	WILLIS
State	:	TX
Zip	:	77378-8830
Country	:	US
Telephone Number	:	936-890-8000
Fax Number	:	936-890-9000

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	11/27/2023

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Directions to “ KELLI CRISP RN” Practice Location

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