Basic Information
| Provider Information | |||||||||
| NPI: | 1114673951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVY | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | EMELINE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN, FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 4370 MEDICAL ARTS DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | FLOWER MOUND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750281713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725374100 | ||||||||
| FaxNumber: | 9725374104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2022 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1068869 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.