Provider Demographics
NPI:1093411779
Name:FORD, KALLIE
Entity type:Individual
Prefix:MRS
First Name:KALLIE
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 FOUNTAIN HEAD DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-6316
Mailing Address - Country:US
Mailing Address - Phone:972-900-9989
Mailing Address - Fax:
Practice Address - Street 1:2235 S GOLIAD ST STE 110
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-4903
Practice Address - Country:US
Practice Address - Phone:469-495-9142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1110016363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily