Provider Demographics
NPI:1174298624
Name:KELLEY, DANA MONROE
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:MONROE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:MONROE
Other - Last Name:DYE KELLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:31772 CASINO DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4502
Mailing Address - Country:US
Mailing Address - Phone:951-674-9400
Mailing Address - Fax:
Practice Address - Street 1:31772 CASINO DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4502
Practice Address - Country:US
Practice Address - Phone:951-674-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator