Provider Demographics
NPI:1942808795
Name:KELLY, SAMMIE BEATRICE (RN)
Entity type:Individual
Prefix:
First Name:SAMMIE
Middle Name:BEATRICE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 MOBILE AVE APT 1224
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-0573
Mailing Address - Country:US
Mailing Address - Phone:972-799-1109
Mailing Address - Fax:
Practice Address - Street 1:5700 MOBILE AVE APT 1224
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-0573
Practice Address - Country:US
Practice Address - Phone:972-799-1109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX977457163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse