Provider Demographics
NPI:1538255344
Name:WILSON, KELLY E
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6448 BROMPTON
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055
Mailing Address - Country:US
Mailing Address - Phone:713-839-0581
Mailing Address - Fax:
Practice Address - Street 1:7400 FANNIN SUITE 930
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054
Practice Address - Country:US
Practice Address - Phone:713-796-8200
Practice Address - Fax:713-796-8203
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9443174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG39294Medicare UPIN