Healthcare Provider Details

I. General information

NPI: 1982900114
Provider Name (Legal Business Name): SHAUNA KELLY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2011
Last Update Date: 02/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 JOSEPH DR
BRYAN TX
77802-1502
US

IV. Provider business mailing address

64 DANBURY RD
WILTON CT
06897-4429
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-2411
  • Fax: 979-776-4986
Mailing address:
  • Phone: 800-278-0332
  • Fax: 800-970-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number1195167
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: