Healthcare Provider Details

I. General information

NPI: 1689179376
Provider Name (Legal Business Name): KELLY DZIERSK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6911 RR 620 N
AUSTIN TX
78732-1920
US

IV. Provider business mailing address

12600 MAIDENHAIR LN
BEE CAVE TX
78738-5617
US

V. Phone/Fax

Practice location:
  • Phone: 512-219-8533
  • Fax:
Mailing address:
  • Phone: 512-909-4574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number35432
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: