Healthcare Provider Details

I. General information

NPI: 1295098085
Provider Name (Legal Business Name): KELLUM ROBERT TICE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21214 NORTHWEST FWY
CYPRESS TX
77429-3373
US

IV. Provider business mailing address

9301 S WESTERN AVE
OKLAHOMA CITY OK
73139-2767
US

V. Phone/Fax

Practice location:
  • Phone: 832-912-3500
  • Fax:
Mailing address:
  • Phone: 866-321-8433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number730287
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: