Provider Demographics
NPI:1104563493
Name:MCKERNAN, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:MCKERNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E ESPLANADE DR STE 660
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-0530
Mailing Address - Country:US
Mailing Address - Phone:805-981-2883
Mailing Address - Fax:
Practice Address - Street 1:500 E ESPLANADE DR STE 660
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0530
Practice Address - Country:US
Practice Address - Phone:805-981-2883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN190923164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse