Provider Demographics
NPI:1588164826
Name:KELLEY, MICHAEL L (RN, BSN, IBCLC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 LAKE KATHLEEN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3131
Mailing Address - Country:US
Mailing Address - Phone:619-972-7792
Mailing Address - Fax:
Practice Address - Street 1:6334 LAKE KATHLEEN AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-3131
Practice Address - Country:US
Practice Address - Phone:619-972-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-13
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025388163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse