Provider Demographics
NPI:1619157187
Name:THUE, KELLY MACKENZIE (RN, BSN, PHN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MACKENZIE
Last Name:THUE
Suffix:
Gender:F
Credentials:RN, BSN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3829 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804
Mailing Address - Country:US
Mailing Address - Phone:714-834-8505
Mailing Address - Fax:714-834-7977
Practice Address - Street 1:1725 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-2316
Practice Address - Country:US
Practice Address - Phone:714-834-8505
Practice Address - Fax:714-834-7977
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA605070163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health