Provider Demographics
NPI:1285413880
Name:MARTIN, KELLY ELIZABETH (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 MERLIN DR
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-2527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 MERLIN DR
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-2527
Practice Address - Country:US
Practice Address - Phone:501-712-6209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022016427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily