Provider Demographics
NPI:1558718692
Name:COFFMAN, KELLIE L
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:L
Last Name:COFFMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:L
Other - Last Name:FULBRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5245 CONLEY LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-1491
Mailing Address - Country:US
Mailing Address - Phone:707-386-8808
Mailing Address - Fax:
Practice Address - Street 1:5245 CONLEY LN
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-1491
Practice Address - Country:US
Practice Address - Phone:707-386-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst