Provider Demographics
NPI:1699226415
Name:KELLY, KATHLEEN ANN (PHD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DAVID GEFFEN MEDICAL CTR UCLA 10833 LE CONTE AVE
Mailing Address - Street 2:MAILROOM A3-215 CHS, MAILCODE 173216
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1732
Mailing Address - Country:US
Mailing Address - Phone:310-206-5562
Mailing Address - Fax:310-794-4863
Practice Address - Street 1:DAVID GEFFEN MEDICAL CTR UCLA 10833 LE CONTE AVE
Practice Address - Street 2:MAILROOM A3-215 CHS, MAILCODE 173216
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1732
Practice Address - Country:US
Practice Address - Phone:310-206-5562
Practice Address - Fax:310-794-4863
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADRH01006488291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory