Healthcare Provider Details

I. General information

NPI: 1063873602
Provider Name (Legal Business Name): KELLEY K. MENEFEE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 W ROSEDALE ST STE 100
FORT WORTH TX
76104-7437
US

IV. Provider business mailing address

P.O. BOX 961205
FORT WORTH TX
76161-1205
US

V. Phone/Fax

Practice location:
  • Phone: 817-930-2030
  • Fax: 817-930-2031
Mailing address:
  • Phone: 817-740-8400
  • Fax: 817-378-3699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10483
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: