Provider Demographics
NPI:1033493747
Name:PATEL, KELLY MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:PATEL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:KRUCZEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-906-4564
Practice Address - Street 1:3705 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-7104
Practice Address - Country:US
Practice Address - Phone:619-515-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004735363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95004735OtherLIC