Provider Demographics
NPI:1497719504
Name:FRANCIS, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FRANCIS
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 1:18111 BROOKHURST ST
Mailing Address - Street 2:SUITE 6400
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6728
Mailing Address - Country:US
Mailing Address - Phone:714-350-7258
Mailing Address - Fax:714-963-1234
Practice Address - Street 1:18111 BROOKHURST ST
Practice Address - Street 2:SUITE 6400
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-350-7258
Practice Address - Fax:714-963-1234
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71155174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A711550Medicaid
CAG23625Medicare UPIN
CA00A711550Medicaid