Provider Demographics
NPI:1043422652
Name:HAMILTON, KELLIE LYNN (IDC)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:LYNN
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 AGUIRRE DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-8176
Mailing Address - Country:US
Mailing Address - Phone:619-392-8754
Mailing Address - Fax:
Practice Address - Street 1:NAVAL SCHOOL OF HEALTH SCIENCES
Practice Address - Street 2:34101 FARENHOLT AVE, BLD 14
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134
Practice Address - Country:US
Practice Address - Phone:619-532-6094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman