=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023367208
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY JO KOSS WHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2012
-----------------------------------------------------
Last Update Date | 02/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1534 MISTY HOLW
-----------------------------------------------------
City | NEW BRAUNFELS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78132-2732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-731-8994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 MAVERICK CT
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76049-1381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-731-8994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 811550
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------