Provider Demographics
NPI:1639489727
Name:HERNANDEZ, KELLI KAYE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:KAYE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:KELLI
Other - Middle Name:KAYE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:700 S TUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-3425
Mailing Address - Country:US
Mailing Address - Phone:714-922-4100
Mailing Address - Fax:
Practice Address - Street 1:700 S TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-3425
Practice Address - Country:US
Practice Address - Phone:714-922-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21159363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant