Provider Demographics
NPI:1114293255
Name:HER, KELLY (AC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:HER
Suffix:
Gender:F
Credentials:AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 BLUEBONNET AVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-3566
Mailing Address - Country:US
Mailing Address - Phone:805-302-0266
Mailing Address - Fax:
Practice Address - Street 1:970 PETIT AVE STE D
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-2215
Practice Address - Country:US
Practice Address - Phone:805-302-0266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine