Healthcare Provider Details

I. General information

NPI: 1255516944
Provider Name (Legal Business Name): KELLEY ELAINE PENNELL CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2008
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 SCHERTZ PKWY STE 400
SCHERTZ TX
78154-1457
US

IV. Provider business mailing address

PO BOX 117475
CARROLLTON TX
75011-7475
US

V. Phone/Fax

Practice location:
  • Phone: 210-495-7246
  • Fax: 210-495-7245
Mailing address:
  • Phone: 210-495-7246
  • Fax: 210-495-7245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number709818
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: