Healthcare Provider Details

I. General information

NPI: 1477028876
Provider Name (Legal Business Name): PATTY MATHIS KELLEY BSN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E FERGUSON ST
TYLER TX
75702-5759
US

IV. Provider business mailing address

545 PRAIRIE DELL ST
LEWISVILLE TX
75067-3603
US

V. Phone/Fax

Practice location:
  • Phone: 903-705-0070
  • Fax:
Mailing address:
  • Phone: 806-339-1420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number753299
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: