Healthcare Provider Details

I. General information

NPI: 1801308556
Provider Name (Legal Business Name): KELLI KOVACH HARTMANN MSN, RN, AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLI NOEL KOVACH RN

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 W IH 10
SAN ANTONIO TX
78201-2009
US

IV. Provider business mailing address

1132 LAKESIDE DR
LAKEHILLS TX
78063-6477
US

V. Phone/Fax

Practice location:
  • Phone: 210-736-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberAP135682
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP135682
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: