Provider Demographics
NPI:1598388316
Name:AVILA, KELLY T (RN, PHN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:T
Last Name:AVILA
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:TAPSCOTT
Other - Last Name:AVILA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, PHN
Mailing Address - Street 1:260 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6216
Mailing Address - Country:US
Mailing Address - Phone:209-381-1029
Mailing Address - Fax:209-724-4007
Practice Address - Street 1:260 E 15TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6216
Practice Address - Country:US
Practice Address - Phone:209-381-1029
Practice Address - Fax:209-724-4007
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95094797163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse