Provider Demographics
NPI:1700403524
Name:PHILLIPS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PHILLIPS
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 1:4650 FRUITVALE RD
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:CA
Mailing Address - Zip Code:95658-9240
Mailing Address - Country:US
Mailing Address - Phone:530-488-0713
Mailing Address - Fax:
Practice Address - Street 1:4650 FRUITVALE RD
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:CA
Practice Address - Zip Code:95658-9240
Practice Address - Country:US
Practice Address - Phone:530-488-0713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-27
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1744G0900X
CAZ3756174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No1744G0900XOther Service ProvidersSpecialistGraphics DesignerGroup - Single Specialty