Provider Demographics
NPI:1336405083
Name:PHELPS, KELSEY ELAINE
Entity type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:ELAINE
Last Name:PHELPS
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 1:1179 N MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6559
Mailing Address - Country:US
Mailing Address - Phone:707-559-7500
Mailing Address - Fax:707-559-7707
Practice Address - Street 1:3 SIXTH ST.
Practice Address - Street 2:
Practice Address - City:POINT REYES STATION
Practice Address - State:CA
Practice Address - Zip Code:94956
Practice Address - Country:US
Practice Address - Phone:707-559-7500
Practice Address - Fax:707-559-7707
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206345207Q00000X
CA169693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine