Provider Demographics
NPI:1427794833
Name:KELLEY, SARA MARCIADENE (JD)
Entity type:Individual
Prefix:MS
First Name:SARA
Middle Name:MARCIADENE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8825 AERO DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2268
Mailing Address - Country:US
Mailing Address - Phone:619-455-8622
Mailing Address - Fax:
Practice Address - Street 1:8825 AERO DR STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2268
Practice Address - Country:US
Practice Address - Phone:619-455-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker