Basic Information
Provider Information
NPI: 1366632804
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HARGRAVE
FirstName: KELLI
MiddleName: L.
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1000 FM 300
Address2:  
City: LEVELLAND
State: TX
PostalCode: 793366235
CountryCode: US
TelephoneNumber: 8068971987
FaxNumber: 8068943378
Practice Location
Address1: 1000 FM 300
Address2:  
City: LEVELLAND
State: TX
PostalCode: 793366235
CountryCode: US
TelephoneNumber: 8068971987
FaxNumber: 8068943378
Other Information
ProviderEnumerationDate: 07/31/2007
LastUpdateDate: 07/31/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000X14772TXY Dental ProvidersDental Hygienist 

No ID Information.


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