MEDICARE: KELLY HALE 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	AP133022	TX

General Provider Information

NPI Number	:	1942733589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY HALE APRN

Provider Business Mailing Address
First Line	:	9557 N BEACH ST
Second Line	:	STE 121
City	:	FORT WORTH
State	:	TX
Zip	:	76244-6395
Country	:	US
Telephone Number	:	817-741-5050
Fax Number	:	817-741-5059

Provider Business Practice Location Address
First Line	:	9557 N BEACH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-6395
Country	:	US
Telephone Number	:	817-741-5050
Fax Number	:

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

Provider Enumeration Date	:	04/11/2017
Last Update Date	:	05/17/2017

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