Basic Information
| Provider Information | |||||||||
| NPI: | 1174980437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, APRN, AGCNS-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7800 SHOAL CREEK BLVD STE 130W | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787571040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124078880 | ||||||||
| FaxNumber: | 5124078681 | ||||||||
| Practice Location | |||||||||
| Address1: | 7800 SHOAL CREEK BLVD STE 130W | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124078880 | ||||||||
| FaxNumber: | 5124078681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2016 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SG0600X | AP129019 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 1174980437 | 05 | TX | MEDICAID | AP129019 | 01 | TX | TEXAS APRN LICENSE NUMBER | OTHER |