MEDICARE: DR. KELLIE RUTH KING APRN

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	363LF0000X	Family Nurse Practitioner	11009343	FL
2	363LF0000X	Family Nurse Practitioner	1017997	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

General Provider Information

NPI Number	:	1316554264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLIE RUTH KING APRN

Provider Business Mailing Address
First Line	:	5605 N MACARTHUR BLVD STE 400
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75038-2693
Country	:	US
Telephone Number	:	469-400-4784
Fax Number	:

Provider Business Practice Location Address
First Line	:	5937 DONNELLY AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-5811
Country	:	US
Telephone Number	:	682-212-9140
Fax Number	:

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

Provider Enumeration Date	:	09/24/2020
Last Update Date	:	03/28/2023

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