Provider Demographics
NPI:1144426297
Name:LIAO, KELLY CHEN (NP, RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CHEN
Last Name:LIAO
Suffix:
Gender:F
Credentials:NP, RN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CHEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:10573 WELLWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1245 16TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1235
Practice Address - Country:US
Practice Address - Phone:310-453-9010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 11745363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics