MEDICARE: SHAWNA LYNN KELLEY

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	164X00000X	Licensed Vocational Nurse	341392	TX

General Provider Information

NPI Number	:	1275190902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWNA LYNN KELLEY

Provider Business Mailing Address
First Line	:	18706 LANGLEY POND LN
Second Line	:
City	:	NEW CANEY
State	:	TX
Zip	:	77357-1546
Country	:	US
Telephone Number	:	832-416-3605
Fax Number	:

Provider Business Practice Location Address
First Line	:	18706 LANGLEY POND LN
Second Line	:
City	:	NEW CANEY
State	:	TX
Zip	:	77357-1546
Country	:	US
Telephone Number	:	832-416-3605
Fax Number	:

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

Provider Enumeration Date	:	05/29/2019
Last Update Date	:	05/29/2019

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