Healthcare Provider Details

I. General information

NPI: 1205478021
Provider Name (Legal Business Name): STACEY RACHELLE KELLY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 21ST ST 507
LUBBOCK TX
79410-1105
US

IV. Provider business mailing address

2215 NASHVILLE AVENUE
LUBBOCK TX
79410-1106
US

V. Phone/Fax

Practice location:
  • Phone: 806-725-4800
  • Fax:
Mailing address:
  • Phone: 806-725-5844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP143497
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: