Provider Demographics
NPI:1902116742
Name:BRICK, KELLEY M
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:M
Last Name:BRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:M
Other - Last Name:COBERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6023 SHEPHERD DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2251
Mailing Address - Country:US
Mailing Address - Phone:909-693-2327
Mailing Address - Fax:
Practice Address - Street 1:550 N FLOWER ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-2361
Practice Address - Country:US
Practice Address - Phone:714-647-4164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240145164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse