Healthcare Provider Details

I. General information

NPI: 1861695728
Provider Name (Legal Business Name): KELLY RENEE REAGAN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W 38TH ST STE. 109
AUSTIN TX
78705-1000
US

IV. Provider business mailing address

1301 W 38TH ST STE. 109
AUSTIN TX
78705-1000
US

V. Phone/Fax

Practice location:
  • Phone: 512-533-4171
  • Fax: 512-452-7947
Mailing address:
  • Phone: 512-533-4171
  • Fax: 512-452-7947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number583325
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: