Provider Demographics
NPI:1861969073
Name:RODRIGUEZ-KELLY, STACY MICHELLE
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MICHELLE
Last Name:RODRIGUEZ-KELLY
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 1:3215 DEFOREST ROAD
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933
Mailing Address - Country:US
Mailing Address - Phone:831-402-3263
Mailing Address - Fax:
Practice Address - Street 1:23625 HOLMAN HWY
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5902
Practice Address - Country:US
Practice Address - Phone:831-625-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008637363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care