Provider Demographics
NPI:1184206328
Name:GRAMILLO, KELLY (BA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRAMILLO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 S MEDNIK AVE # 201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-1606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:149 S MEDNIK AVE # 201
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1606
Practice Address - Country:US
Practice Address - Phone:626-423-2973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner