Provider Demographics
NPI:1992287742
Name:DAVIS, KELLIE HORN
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:HORN
Last Name:DAVIS
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 1:142 COUNTY ROAD 3325
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-7727
Mailing Address - Country:US
Mailing Address - Phone:903-563-0280
Mailing Address - Fax:
Practice Address - Street 1:142 COUNTY ROAD 3325
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-7727
Practice Address - Country:US
Practice Address - Phone:903-563-0280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX148784164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse