Provider Demographics
NPI:1518390533
Name:VIRS, KELLY (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VIRS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 JAZMIN AVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1827
Mailing Address - Country:US
Mailing Address - Phone:805-258-6286
Mailing Address - Fax:
Practice Address - Street 1:689 JAZMIN AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1827
Practice Address - Country:US
Practice Address - Phone:805-258-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA848002163W00000X
CA95025197363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA163W00000XOtherREGISTERED NURSE