Healthcare Provider Details

I. General information

NPI: 1073622858
Provider Name (Legal Business Name): KELLEY D ELLIS RNFA, CNOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MISTLETOE BLVD STE 200
FORT WORTH TX
76104-4049
US

IV. Provider business mailing address

1900 MISTLETOE BLVD STE 200
FORT WORTH TX
76104-4049
US

V. Phone/Fax

Practice location:
  • Phone: 817-878-5333
  • Fax: 817-878-5334
Mailing address:
  • Phone: 817-878-5333
  • Fax: 817-878-5334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number551667
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: