Provider Demographics
NPI:1699800805
Name:LUNZER, KELLY NICOLE (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:LUNZER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:LUNZER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:3445 PACIFIC COAST HIGHWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505
Mailing Address - Country:US
Mailing Address - Phone:310-542-6333
Mailing Address - Fax:310-542-4695
Practice Address - Street 1:3445 PACIFIC COAST HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6658
Practice Address - Country:US
Practice Address - Phone:310-542-6333
Practice Address - Fax:310-542-4695
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18669363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical