Provider Demographics
NPI:1770822116
Name:KELLEY, HARUKA
Entity Type:Individual
Prefix:
First Name:HARUKA
Middle Name:
Last Name: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 1:2350 W EL CAMINO REAL FL 2
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6203
Mailing Address - Country:US
Mailing Address - Phone:510-204-5600
Mailing Address - Fax:510-506-7722
Practice Address - Street 1:2500 MILVIA ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704
Practice Address - Country:US
Practice Address - Phone:510-204-5600
Practice Address - Fax:510-506-7722
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007416363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95007416OtherSTATE MEDICAL LICENSE