Provider Demographics
NPI:1265850127
Name:SCANNELL, KELLIE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:SCANNELL
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28201 MARGUERITE PKWY
Mailing Address - Street 2:#13
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-3719
Mailing Address - Country:US
Mailing Address - Phone:949-364-3928
Mailing Address - Fax:
Practice Address - Street 1:28201 MARGUERITE PKWY
Practice Address - Street 2:#13
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-3719
Practice Address - Country:US
Practice Address - Phone:949-364-3928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA529605163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0150193OtherMEDI-CAL