Healthcare Provider Details

I. General information

NPI: 1831709161
Provider Name (Legal Business Name): KELSEY ANN KOMECHAK NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2020
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 W WALKER ST
BRECKENRIDGE TX
76424-4000
US

IV. Provider business mailing address

PO BOX 679
CLYDE TX
79510-0679
US

V. Phone/Fax

Practice location:
  • Phone: 254-559-7215
  • Fax:
Mailing address:
  • Phone: 325-893-4010
  • Fax: 325-893-4035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP144537
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: