MEDICARE: KELLY LYNN NUNEMAKER APRN

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	AP137130	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AP137130	OTHER	TX	TEXAS NURSING BOARD

General Provider Information

NPI Number	:	1629567896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LYNN NUNEMAKER APRN

Provider Business Mailing Address
First Line	:	4118 POND HILL RD
Second Line	:
City	:	SHAVANO PARK
State	:	TX
Zip	:	78231-1281
Country	:	US
Telephone Number	:	210-494-3739
Fax Number	:	210-494-4508

Provider Business Practice Location Address
First Line	:	4118 POND HILL RD
Second Line	:
City	:	SHAVANO PARK
State	:	TX
Zip	:	78231-1281
Country	:	US
Telephone Number	:	210-494-4508
Fax Number	:	210-494-4508

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

Provider Enumeration Date	:	05/03/2018
Last Update Date	:	10/02/2024

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