Provider Demographics
NPI:1144543695
Name:STEPHENS, KELLY MARIE (RN, NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 ALAMO ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1311
Mailing Address - Country:US
Mailing Address - Phone:801-361-7757
Mailing Address - Fax:
Practice Address - Street 1:2755 ALAMO ST STE 101
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1311
Practice Address - Country:US
Practice Address - Phone:801-361-7757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA711642163W00000X
CA19629363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1144543695OtherNPI