=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568064194
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY MAE HERNANDEZ AGACNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2020
-----------------------------------------------------
Last Update Date | 11/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 WALLACE BLVD
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-1799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-212-2129
-----------------------------------------------------
Fax | 806-212-2246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 840026
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75284-0026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-212-6965
-----------------------------------------------------
Fax | 806-212-6278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Clinical Nurse Specialist
-----------------------------------------------------
License Number | 1012436
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 1012436
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------