Basic Information
| Provider Information | |||||||||
| NPI: | 1548697014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAMADALIYEV | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | MASK | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SANTA ROSA ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107044038 | ||||||||
| FaxNumber: | 2107044520 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 N SANTA ROSA ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107044038 | ||||||||
| FaxNumber: | 2107044520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2013 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 720441 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.