Provider Demographics
NPI:1255516944
Name:PENNELL, KELLEY ELAINE (CNS)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:ELAINE
Last Name:PENNELL
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 117475
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75011-7475
Mailing Address - Country:US
Mailing Address - Phone:210-495-7246
Mailing Address - Fax:210-495-7245
Practice Address - Street 1:5000 SCHERTZ PKWY STE 400
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-1457
Practice Address - Country:US
Practice Address - Phone:210-495-7246
Practice Address - Fax:210-495-7245
Is Sole Proprietor?:No
Enumeration Date:2008-01-01
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX709818364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX338214YRMQMedicare PIN