Provider Demographics
NPI:1811105414
Name:BOSCH, KELLEEN MICHELLE (DO)
Entity type:Individual
Prefix:
First Name:KELLEEN
Middle Name:MICHELLE
Last Name:BOSCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1374 E ALLUVIAL AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2608
Mailing Address - Country:US
Mailing Address - Phone:559-981-2600
Mailing Address - Fax:559-981-2610
Practice Address - Street 1:1374 E ALLUVIAL AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2608
Practice Address - Country:US
Practice Address - Phone:559-981-2600
Practice Address - Fax:559-981-2610
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9211207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics