Provider Demographics
NPI:1700046430
Name:COLLINS-KELLEY, VIVIAN
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:COLLINS-KELLEY
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 1:48304 85TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-8700
Mailing Address - Country:US
Mailing Address - Phone:661-839-8879
Mailing Address - Fax:
Practice Address - Street 1:48304 85TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-8700
Practice Address - Country:US
Practice Address - Phone:661-839-8879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282J00000XHospitalsReligious Nonmedical Health Care Institution