Provider Demographics
NPI:1861901159
Name:KELLY, KATHLEEN WILLIS (PHARM D)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:WILLIS
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 TUSCAN GROVE CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-8376
Mailing Address - Country:US
Mailing Address - Phone:707-330-3496
Mailing Address - Fax:
Practice Address - Street 1:7901 WALERGA RD
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-5722
Practice Address - Country:US
Practice Address - Phone:916-725-6940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist