Provider Demographics
NPI:1497508303
Name:KELLY, TAKEYSHA (FNP-C)
Entity Type:Individual
Prefix:
First Name:TAKEYSHA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13569 WILLIAMSON RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2071
Mailing Address - Country:US
Mailing Address - Phone:909-240-8629
Mailing Address - Fax:
Practice Address - Street 1:350 TERRACINA BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4850
Practice Address - Country:US
Practice Address - Phone:909-335-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029714363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily