Provider Demographics
NPI:1336746890
Name:URTIAGA, KELLY (LAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:URTIAGA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 E VISTA RIDGE MALL DR APT 824
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-4084
Mailing Address - Country:US
Mailing Address - Phone:210-275-0451
Mailing Address - Fax:
Practice Address - Street 1:5310 HARVEST HILL RD STE 135
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-5845
Practice Address - Country:US
Practice Address - Phone:214-471-5577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01970171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty