Provider Demographics
NPI:1124547369
Name:CHUNG, KELSEY (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N TUSTIN AVE STE G
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3605
Mailing Address - Country:US
Mailing Address - Phone:714-547-6111
Mailing Address - Fax:
Practice Address - Street 1:800 N TUSTIN AVE STE G
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3605
Practice Address - Country:US
Practice Address - Phone:714-547-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95007381363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124547369OtherNPI