Provider Demographics
NPI:1841239738
Name:NEELY, KIMBERLY R (GNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:NEELY
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 E MAIN ST STE 200
Mailing Address - Street 2:BOX 118
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-3365
Mailing Address - Country:US
Mailing Address - Phone:972-903-4343
Mailing Address - Fax:800-782-4295
Practice Address - Street 1:231 S COLLINS RD
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-4624
Practice Address - Country:US
Practice Address - Phone:972-892-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX631908163WG0600X
TXAP107482363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNBC/BSOther8N7188
TX117391607Medicaid
TX8B5812Medicare PIN
TXP00116308Medicare PIN
TX117391607Medicaid