Provider Demographics
NPI:1285956391
Name:BRASSIL, KELLY JEAN (APN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:BRASSIL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:FALTUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:P O BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX778238363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX817N17OtherBCBS
TX216347901Medicaid
TX216347901Medicaid