Healthcare Provider Details

I. General information

NPI: 1760619639
Provider Name (Legal Business Name): KELLY C WARREN R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MCKENZIE ST
FORT WORTH TX
76105-3053
US

IV. Provider business mailing address

2000 MCKENZIE ST
FORT WORTH TX
76105-3053
US

V. Phone/Fax

Practice location:
  • Phone: 817-534-0814
  • Fax:
Mailing address:
  • Phone: 817-534-0814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number607991
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: