Provider Demographics
NPI:1417282278
Name:NGUYEN, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:NGUYEN
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 1:195 E SAN FERNANDO ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-3503
Mailing Address - Country:US
Mailing Address - Phone:408-889-7154
Mailing Address - Fax:408-516-9488
Practice Address - Street 1:195 E SAN FERNADO STREET
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5569
Practice Address - Country:US
Practice Address - Phone:408-889-7154
Practice Address - Fax:408-516-9488
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN241285164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse