Provider Demographics
NPI:1629057237
Name:KALIS, VANESSA MARIA (NP)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:MARIA
Last Name:KALIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 CORPORATE DR
Mailing Address - Street 2:STE 102
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-2113
Mailing Address - Country:US
Mailing Address - Phone:949-276-2446
Mailing Address - Fax:
Practice Address - Street 1:27800 MEDICAL CENTER RD
Practice Address - Street 2:SUITE 222
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6410
Practice Address - Country:US
Practice Address - Phone:949-276-2446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA14401363LA2100X
CA1901364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ22150Medicare UPIN