Provider Demographics
NPI:1730642141
Name:ROSENBERRY, KELLY A
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:ROSENBERRY
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 1:7741 GODDARD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3221
Mailing Address - Country:US
Mailing Address - Phone:310-926-2853
Mailing Address - Fax:800-767-1867
Practice Address - Street 1:7741 GODDARD AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3221
Practice Address - Country:US
Practice Address - Phone:310-926-2853
Practice Address - Fax:800-767-1867
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA666751163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA666751OtherBOARD OF REGISTERED NURSING