Provider Demographics
NPI:1730634270
Name:OWEN, KAELY
Entity type:Individual
Prefix:
First Name:KAELY
Middle Name:
Last Name:OWEN
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 1:7117 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2658
Mailing Address - Country:US
Mailing Address - Phone:951-683-6370
Mailing Address - Fax:
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2658
Practice Address - Country:US
Practice Address - Phone:951-683-6370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA801616163W00000X
CA95004779363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse