Provider Demographics
NPI:1659464071
Name:KELLY, NAN MARIE (NP)
Entity Type:Individual
Prefix:MS
First Name:NAN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:NAN
Other - Middle Name:MARIE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:P.O. BOX 391700
Mailing Address - Street 2:ANZA COMMUNITY CLINIC
Mailing Address - City:ANZA
Mailing Address - State:CA
Mailing Address - Zip Code:92539-1700
Mailing Address - Country:US
Mailing Address - Phone:951-763-5000
Mailing Address - Fax:951-763-5003
Practice Address - Street 1:44225 BARBARA TRL
Practice Address - Street 2:
Practice Address - City:AGUANGA
Practice Address - State:CA
Practice Address - Zip Code:92536-9654
Practice Address - Country:US
Practice Address - Phone:951-763-5634
Practice Address - Fax:951-763-5634
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA216481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR95717Medicare UPIN