Provider Demographics
NPI:1801497284
Name:RACKHAM, KELLY (FNP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RACKHAM
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:844-308-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015717363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95015717OtherSTATE BON