=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457135170
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY JADE KELLER NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2023
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27010 FLINTLOCK TRL
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77354-7202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-726-6162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27010 FLINTLOCK TRL
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77354-7202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-726-6162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1126813
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------