Provider Demographics
NPI:1760525026
Name:QUAN, KELLIE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:QUAN
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 1:14449 BENEFIT ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-4037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6000 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-6310
Practice Address - Country:US
Practice Address - Phone:310-770-2842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR531351835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric