1689045957 NPI number — KELSEY ELIZABETH REEKIE AGACNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689045957 NPI number — KELSEY ELIZABETH REEKIE AGACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REEKIE
Provider First Name:
KELSEY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGACNP
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:
1689045957
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3315 COLORADO BLVD
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
DENTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76210-6885
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-320-1708
Provider Business Mailing Address Fax Number:
940-565-5457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4240 INTERNATIONAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 154
Provider Business Practice Location Address City Name:
CARROLLTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75007-1970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-574-0464
Provider Business Practice Location Address Fax Number:
469-574-0471
Provider Enumeration Date:
10/13/2015

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: 363LA2100X , with the licence number:  AP129339 , 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: 354727501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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