Provider Demographics
NPI:1992521181
Name:BREEN, KELLIE ROSE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ROSE
Last Name:BREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6242 WARNER AVE APT 4H
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-5190
Mailing Address - Country:US
Mailing Address - Phone:714-316-8706
Mailing Address - Fax:
Practice Address - Street 1:680 LANGSDORF DR STE 200
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3702
Practice Address - Country:US
Practice Address - Phone:714-871-9264
Practice Address - Fax:714-871-5032
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program