Basic Information
Provider Information | |||||||||
NPI: | 1003389784 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELLY | ||||||||
FirstName: | SHERILYN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WIGHT | ||||||||
OtherFirstName: | SHERILYN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1904 JAKE ANDREW AVE | ||||||||
Address2: |   | ||||||||
City: | NORTH LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 890861372 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4357709028 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7600 FANNIN ST | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770541906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7137901234 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2019 | ||||||||
LastUpdateDate: | 01/06/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | 889433 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
No ID Information.