MEDICARE: MRS. NAKIA DEONTRANISE KELLEY-HUMPHREY STA

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	2355S0801X	Speech-Language Assistant	42457	TX

General Provider Information

NPI Number	:	1073251716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NAKIA DEONTRANISE KELLEY-HUMPHREY STA

Provider Business Mailing Address
First Line	:	9425 CHUPAROSA DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-7246
Country	:	US
Telephone Number	:	256-919-7464
Fax Number	:

Provider Business Practice Location Address
First Line	:	9425 CHUPAROSA DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-7246
Country	:	US
Telephone Number	:	256-919-7464
Fax Number	:

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

Provider Enumeration Date	:	05/23/2022
Last Update Date	:	05/23/2022

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