Basic Information
| Provider Information | |||||||||
| NPI: | 1760079727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | KATEY | ||||||||
| MiddleName: | ZELLE | ||||||||
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| Credential: | DNP, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2255 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761101962 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177023431 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2020 | ||||||||
| LastUpdateDate: | 02/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 881802 | TX | N | Nursing Service Providers | Registered Nurse | 367500000X | 1026896 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.