Provider Demographics
NPI:1457491763
Name:KELLEY, JOHN CHRISTOPHER (RN PHN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:KELLEY
Suffix:
Gender:M
Credentials:RN PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-4932
Mailing Address - Country:US
Mailing Address - Phone:707-444-3697
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:707-268-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA600664163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse