Provider Demographics
NPI:1194503391
Name:KELLEY, MATILDA DENISE (BSN, RN, CLT)
Entity type:Individual
Prefix:MRS
First Name:MATILDA
Middle Name:DENISE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:BSN, RN, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2699 MARION ST
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-8192
Mailing Address - Country:US
Mailing Address - Phone:409-201-5293
Mailing Address - Fax:
Practice Address - Street 1:2750 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-3435
Practice Address - Country:US
Practice Address - Phone:409-659-7306
Practice Address - Fax:409-422-0050
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX769373163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse