Provider Demographics
NPI:1275156374
Name:KELLY, JOSEPHINE RAYE
Entity Type:Individual
Prefix:MS
First Name:JOSEPHINE
Middle Name:RAYE
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 CARQUINEZ AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94805-2002
Mailing Address - Country:US
Mailing Address - Phone:510-332-2466
Mailing Address - Fax:
Practice Address - Street 1:7200 BANCROFT AVE STE 125D
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2424
Practice Address - Country:US
Practice Address - Phone:510-777-3883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program