Provider Demographics
NPI:1366930174
Name:RICH, KELLI (NP-C)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:RICH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 HIGHWAY 6 S
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-4428
Mailing Address - Country:US
Mailing Address - Phone:979-324-4172
Mailing Address - Fax:
Practice Address - Street 1:4421 HIGHWAY 6 S STE 100
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6176
Practice Address - Country:US
Practice Address - Phone:979-731-5200
Practice Address - Fax:979-731-5210
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2022-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137168363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX386646901Medicaid