Provider Demographics
NPI:1528410511
Name:MCKENNA, KELLEY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 W JANSS RD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1848
Mailing Address - Country:US
Mailing Address - Phone:805-852-9100
Mailing Address - Fax:844-442-4951
Practice Address - Street 1:227 W JANSS RD
Practice Address - Street 2:SUITE 340
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1847
Practice Address - Country:US
Practice Address - Phone:805-852-9100
Practice Address - Fax:805-852-9101
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA628910OtherRN REGISTERED NURSE
CA95004481OtherNP