Provider Demographics
NPI:1447418140
Name:ESPINOZA, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ESPINOZA
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 1:15095 AMARGOSA RD STE 208
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-1879
Mailing Address - Country:US
Mailing Address - Phone:760-245-4695
Mailing Address - Fax:
Practice Address - Street 1:2450 S ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-1200
Practice Address - Country:US
Practice Address - Phone:323-887-1917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL