Healthcare Provider Details

I. General information

NPI: 1568774420
Provider Name (Legal Business Name): CHRISTINE KELLAM R.N11
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 S LANCASTER RD
DALLAS TX
75216-4531
US

IV. Provider business mailing address

5731 LAZY RIVER DR
DALLAS TX
75241-2206
US

V. Phone/Fax

Practice location:
  • Phone: 214-371-6639
  • Fax: 214-372-6199
Mailing address:
  • Phone: 214-376-0714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number517241
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number517241
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: