Provider Demographics
NPI:1730449166
Name:MECHAM, KELLY JEAN (APRN, FPN-BC, DNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:MECHAM
Suffix:
Gender:F
Credentials:APRN, FPN-BC, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1801 W OLYMPIC BLVD # 2265
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91199-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:874 AMERICAN PACIFIC DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-8800
Practice Address - Country:US
Practice Address - Phone:702-777-4809
Practice Address - Fax:702-777-4822
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN000780363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVAPN000780OtherLICENSE NO.