Provider Demographics
NPI:1407312093
Name:KELLY, KIERSTEN (MD)
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 HOSPITAL DR STE 103
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-5408
Mailing Address - Country:US
Mailing Address - Phone:916-681-3456
Mailing Address - Fax:
Practice Address - Street 1:7601 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5408
Practice Address - Country:US
Practice Address - Phone:916-423-3456
Practice Address - Fax:916-688-0226
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA186162207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program