Provider Demographics
NPI:1386191856
Name:LEE, KELLY (BSN, RN, PHN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:BSN, RN, PHN
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN, PHN
Mailing Address - Street 1:25 N. COTTONWOOD ST.
Mailing Address - Street 2:ADULT AND AGING BRANCH, YOLO COUNTY HHSA
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695
Mailing Address - Country:US
Mailing Address - Phone:530-666-8451
Mailing Address - Fax:530-661-2673
Practice Address - Street 1:25 N. COTTONWOOD ST.
Practice Address - Street 2:ADULT AND AGING BRANCH, YOLO COUNTY HHSA
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-666-8451
Practice Address - Fax:530-661-2673
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025630163W00000X
CA545994163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse