Healthcare Provider Details

I. General information

NPI: 1891908547
Provider Name (Legal Business Name): KELLY WYLIE D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6730 ATASCOCITA RD STE 108
HUMBLE TX
77346-1995
US

IV. Provider business mailing address

2522 TWISTING PINE CT
KINGWOOD TX
77345-2350
US

V. Phone/Fax

Practice location:
  • Phone: 281-466-8494
  • Fax:
Mailing address:
  • Phone: 915-373-1107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00461
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: