=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639649247
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENDALL LEA SHIREY PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2018
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9509 N BEACH ST STE 101
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76244-6399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-741-4347
-----------------------------------------------------
Fax | 817-741-4483
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 35629
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75235-0629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-424-2213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA12442
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------