Provider Demographics
NPI:1679245310
Name:CHIANG, KELLY IRIS
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:IRIS
Last Name:CHIANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 ALEGRE WAY
Mailing Address - Street 2:
Mailing Address - City:EL MACERO
Mailing Address - State:CA
Mailing Address - Zip Code:95618-7129
Mailing Address - Country:US
Mailing Address - Phone:530-219-8128
Mailing Address - Fax:
Practice Address - Street 1:5850 E STILL CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3618
Practice Address - Country:US
Practice Address - Phone:480-219-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA62090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program