Healthcare Provider Details

I. General information

NPI: 1245720838
Provider Name (Legal Business Name): KELLI D'ANN HARRIS MSN, RN, AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 JOLIET AVE UNIT 220
LUBBOCK TX
79415
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3545
US

V. Phone/Fax

Practice location:
  • Phone: 806-761-0566
  • Fax: 806-744-7252
Mailing address:
  • Phone: 806-761-0333
  • Fax: 806-782-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP137001
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number742224
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: