MEDICARE: MISS CARMISHA KELLUM APRN, FNP-C

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	769783	TX
2	363L00000X	Nurse Practitioner	AP128781	TX

General Provider Information

NPI Number	:	1386001295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CARMISHA KELLUM APRN, FNP-C

Provider Business Mailing Address
First Line	:	25319 HOLTON RIDGE DR
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-1434
Country	:	US
Telephone Number	:	832-620-6988
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 MERRILL ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77009-6009
Country	:	US
Telephone Number	:	713-864-7614
Fax Number	:	713-864-9004

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

Provider Enumeration Date	:	01/22/2016
Last Update Date	:	10/27/2022

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