Healthcare Provider Details

I. General information

NPI: 1104636042
Provider Name (Legal Business Name): KELLI MELISSA BRAZZEL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 COOPER ST
FORT WORTH TX
76104-2710
US

IV. Provider business mailing address

801 7TH AVE
FORT WORTH TX
76104-2796
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-3953
  • Fax: 682-885-7445
Mailing address:
  • Phone: 682-885-3953
  • Fax: 682-885-7445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number581606
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: