Provider Demographics
NPI:1790341857
Name:KELLY, KIRSTEN ANNE (MS, LCGC)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:ANNE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 AVENIDA DE LA GRULLA APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-5023
Mailing Address - Country:US
Mailing Address - Phone:949-280-9722
Mailing Address - Fax:
Practice Address - Street 1:226 AVENIDA DE LA GRULLA APT 4
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-5023
Practice Address - Country:US
Practice Address - Phone:949-280-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS