1306838602 NPI number — MISS CHERYL ANN KELLEY NP

Table of content: MISS CHERYL ANN KELLEY NP (NPI 1306838602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306838602 NPI number — MISS CHERYL ANN KELLEY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
CHERYL
Provider Middle Name:
ANN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306838602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1407 SUNNYVALE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWEETWATER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79556-1922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-933-4224
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5311 BIG SPRING HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SNYDER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79549-6347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-776-2500
Provider Business Practice Location Address Fax Number:
325-776-2355
Provider Enumeration Date:
08/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  240740 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 80N426 . This is a "MEDICARE PART B" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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