Provider Demographics
NPI:1538302799
Name:KELLY, KIM DARRELL (ND, MPH)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:DARRELL
Last Name:KELLY
Suffix:
Gender:M
Credentials:ND, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 BURGUNDY RD
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1847
Mailing Address - Country:US
Mailing Address - Phone:760-533-2883
Mailing Address - Fax:866-353-3603
Practice Address - Street 1:1363 BURGUNDY RD
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1847
Practice Address - Country:US
Practice Address - Phone:760-533-2883
Practice Address - Fax:866-353-3603
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND-130175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath