MEDICARE: KELLY ANNE ELLISON

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	363LA2100X	Acute Care Nurse Practitioner	AP127337	TX
2	363LF0000X	Family Nurse Practitioner	AP127337	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	PENDING	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1265823843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANNE ELLISON

Provider Business Mailing Address
First Line	:	125 DAVIS BLVD
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-8209
Country	:	US
Telephone Number	:	682-212-9104
Fax Number	:

Provider Business Practice Location Address
First Line	:	1980 S MAIN ST
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-5508
Country	:	US
Telephone Number	:	817-598-5616
Fax Number	:

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

Provider Enumeration Date	:	02/18/2015
Last Update Date	:	08/07/2025

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Directions to “ KELLY ANNE ELLISON ” Practice Location

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