Provider Demographics
NPI:1811042120
Name:KELLY, ATA (LAC, MD)
Entity Type:Individual
Prefix:DR
First Name:ATA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LAC, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25272 BENTLEY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4610
Mailing Address - Country:US
Mailing Address - Phone:818-427-8417
Mailing Address - Fax:
Practice Address - Street 1:25272 BENTLEY
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4610
Practice Address - Country:US
Practice Address - Phone:818-427-8417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9891171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist