Healthcare Provider Details

I. General information

NPI: 1710202569
Provider Name (Legal Business Name): KATHY SHELLY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 FANNIN ST SUITE 540
HOUSTON TX
77030-2316
US

IV. Provider business mailing address

6550 FANNIN ST SUITE 1701, ATT: RENEE BROWN
HOUSTON TX
77030-2717
US

V. Phone/Fax

Practice location:
  • Phone: 832-822-3250
  • Fax: 832-825-1622
Mailing address:
  • Phone: 713-798-8291
  • Fax: 713-798-5294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 00264
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: