Provider Demographics
NPI:1063610590
Name:KELLY, SUKESHINI P (RN)
Entity type:Individual
Prefix:
First Name:SUKESHINI
Middle Name:P
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 1:2033 E COLUNGA ST
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-7510
Mailing Address - Country:US
Mailing Address - Phone:909-872-1113
Mailing Address - Fax:909-872-1113
Practice Address - Street 1:2033 E COLUNGA ST
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-7510
Practice Address - Country:US
Practice Address - Phone:909-872-1113
Practice Address - Fax:909-872-1113
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA482520163WC0200X, 163WC0400X, 163WC3500X, 163WE0003X, 163WM0102X, 163WN0002X, 163WU0100X, 163WW0000X, 163WX1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Not Answered163WC0400XNursing Service ProvidersRegistered NurseCase Management
Not Answered163WC3500XNursing Service ProvidersRegistered NurseCardiac Rehabilitation
Not Answered163WE0003XNursing Service ProvidersRegistered NurseEmergency
Not Answered163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
Not Answered163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
Not Answered163WU0100XNursing Service ProvidersRegistered NurseUrology
Not Answered163WW0000XNursing Service ProvidersRegistered NurseWound Care
Not Answered163WX1500XNursing Service ProvidersRegistered NurseOstomy Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPS016950Medicaid
CARVN005060Medicaid