Provider Demographics
NPI:1609361021
Name:VANG, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VANG
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 1:3350 CONCOURS APT 27F
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4891
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2601 W ROSAMOND BLVD
Practice Address - Street 2:
Practice Address - City:ROSAMOND
Practice Address - State:CA
Practice Address - Zip Code:93560-6434
Practice Address - Country:US
Practice Address - Phone:661-256-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool