Provider Demographics
NPI:1043289523
Name:KELLY, MARYPAT (GNP)
Entity Type:Individual
Prefix:
First Name:MARYPAT
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-3455
Mailing Address - Country:US
Mailing Address - Phone:650-473-0529
Mailing Address - Fax:
Practice Address - Street 1:80 GREAT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1310
Practice Address - Country:US
Practice Address - Phone:408-363-3000
Practice Address - Fax:408-363-3082
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15112363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology