Provider Demographics
NPI:1619047271
Name:RICE, NELLY KIM (MD)
Entity Type:Individual
Prefix:MRS
First Name:NELLY
Middle Name:KIM
Last Name:RICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:NELLI
Other - Middle Name:KIM
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PSC 819
Mailing Address - Street 2:BOX 4581
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8808 BALBOA AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1592
Practice Address - Country:US
Practice Address - Phone:619-532-8225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44985207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice