=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811483407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLI FLETCHER NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2018
-----------------------------------------------------
Last Update Date | 07/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 W COLLEGE ST STE 140
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-3575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-692-8262
-----------------------------------------------------
Fax | 214-696-4190
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3600 GASTON AVE STE 1205
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75246-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-692-8262
-----------------------------------------------------
Fax | 214-696-4190
-----------------------------------------------------
=====================================================
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 | AP137221
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------