Provider Demographics
NPI:1508389701
Name:LY, MAN KELLIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MAN
Middle Name:KELLIE
Last Name:LY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4077
Mailing Address - Country:US
Mailing Address - Phone:626-390-2908
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-8035
Practice Address - Fax:310-328-6837
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA615128163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care