Provider Demographics
NPI:1689072316
Name:BROWN, KELLYRAE
Entity Type:Individual
Prefix:
First Name:KELLYRAE
Middle Name:
Last Name:BROWN
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 1:2404 LOMA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-0310
Mailing Address - Country:US
Mailing Address - Phone:916-370-8154
Mailing Address - Fax:
Practice Address - Street 1:1900 PRAIRIE CITY RD
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-9501
Practice Address - Country:US
Practice Address - Phone:916-370-8154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55213171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor