Provider Demographics
NPI:1235368572
Name:VANZUTPHEN, KELLY
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:VANZUTPHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:HUNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1497
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448
Mailing Address - Country:US
Mailing Address - Phone:707-569-4545
Mailing Address - Fax:707-431-2334
Practice Address - Street 1:9940 STARR RD.
Practice Address - Street 2:STE 140
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492
Practice Address - Country:US
Practice Address - Phone:707-569-4545
Practice Address - Fax:707-431-2334
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21716103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist