Provider Demographics
NPI:1568033041
Name:KELLY, KAITLYN MARIE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:KELLY
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 1:17351 MCALLISTER ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-6725
Mailing Address - Country:US
Mailing Address - Phone:951-407-5460
Mailing Address - Fax:
Practice Address - Street 1:2085 RUSTIN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2498
Practice Address - Country:US
Practice Address - Phone:951-955-7263
Practice Address - Fax:951-955-7205
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator