Healthcare Provider Details

I. General information

NPI: 1316322423
Provider Name (Legal Business Name): KELLEY LYNN HANNA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 N BECKLEY AVE PAVILLION 3 STE 152
DALLAS TX
75203-1259
US

IV. Provider business mailing address

3610 ROYAL LN
DALLAS TX
75229-5149
US

V. Phone/Fax

Practice location:
  • Phone: 214-948-7700
  • Fax: 214-948-7701
Mailing address:
  • Phone: 214-293-0390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number61113
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: