Provider Demographics
NPI:1730157454
Name:GROSSMAN, KELLY ALINE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ALINE
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5821 JAMESON CT STE 1
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0820
Mailing Address - Country:US
Mailing Address - Phone:916-864-0411
Mailing Address - Fax:916-797-9414
Practice Address - Street 1:5821 JAMESON CT STE 1
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608
Practice Address - Country:US
Practice Address - Phone:916-864-0411
Practice Address - Fax:916-797-9414
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390508363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS82879Medicare UPIN