Provider Demographics
NPI:1588878623
Name:KELLEY, ELLEN L (NP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:72780 COUNTRY CLUB DR
Mailing Address - Street 2:BLDG B 203
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4126
Mailing Address - Country:US
Mailing Address - Phone:760-674-3847
Mailing Address - Fax:760-674-3845
Practice Address - Street 1:72780 COUNTRY CLUB DR
Practice Address - Street 2:BLDG B 203
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4126
Practice Address - Country:US
Practice Address - Phone:760-674-3847
Practice Address - Fax:760-674-3845
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300549363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS84312Medicare UPIN
CAZZZ16636ZMedicare ID - Type UnspecifiedPART B PROVIDER IDENTIFIC