Provider Demographics
NPI:1265638993
Name:SHIELDS, KELLY (CNM)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3343 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5703
Mailing Address - Country:US
Mailing Address - Phone:619-299-0840
Mailing Address - Fax:619-299-0892
Practice Address - Street 1:3343 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5703
Practice Address - Country:US
Practice Address - Phone:619-299-0840
Practice Address - Fax:619-299-0892
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACNM12240363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA619131OtherRN LICENSE