MEDICARE: KELLY C WARREN R.N.

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	163WP0200X	Pediatric Registered Nurse	607991	TX

General Provider Information

NPI Number	:	1760619639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY C WARREN R.N.

Provider Business Mailing Address
First Line	:	2000 MCKENZIE ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76105-3053
Country	:	US
Telephone Number	:	817-534-0814
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 MCKENZIE ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76105-3053
Country	:	US
Telephone Number	:	817-534-0814
Fax Number	:

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

Provider Enumeration Date	:	06/17/2009
Last Update Date	:	06/17/2009

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