Provider Demographics
NPI:1861944829
Name:SCATTERGOOD, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:SCATTERGOOD
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 1:703 PIER AVE STE B
Mailing Address - Street 2:#125
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3943
Mailing Address - Country:US
Mailing Address - Phone:609-238-4178
Mailing Address - Fax:
Practice Address - Street 1:703 PIER AVE STE B
Practice Address - Street 2:#125
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3943
Practice Address - Country:US
Practice Address - Phone:609-238-4178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004400363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics