Healthcare Provider Details

I. General information

NPI: 1477187185
Provider Name (Legal Business Name): KELLY POTTER BAJAJ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 12/31/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 MATLOCK RD
ARLINGTON TX
76015-2908
US

IV. Provider business mailing address

640 CHERRY TREE DR
KELLER TX
76248-8240
US

V. Phone/Fax

Practice location:
  • Phone: 682-509-6200
  • Fax:
Mailing address:
  • Phone: 817-403-3059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number1477187185
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: