MEDICARE: MRS. KELLI EMELINE IVY APRN, FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1068869	TX

General Provider Information

NPI Number	:	1114673951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLI EMELINE IVY APRN, FNP-BC

Provider Business Mailing Address
First Line	:	6115 NEW COPELAND RD STE 640
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-6368
Country	:	US
Telephone Number	:	903-420-3443
Fax Number	:	903-630-8797

Provider Business Practice Location Address
First Line	:	6115 NEW COPELAND RD STE 640
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-6368
Country	:	US
Telephone Number	:	903-420-3443
Fax Number	:	903-630-8797

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2022
Last Update Date	:	05/20/2026

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