Provider Demographics
NPI:1821672429
Name:KELLEY, MARTHA (RCSN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RCSN
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:BUNIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:24930 AVENUE STANFORD
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1272
Mailing Address - Country:US
Mailing Address - Phone:661-294-5320
Mailing Address - Fax:
Practice Address - Street 1:24930 AVENUE STANFORD
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1272
Practice Address - Country:US
Practice Address - Phone:661-294-5320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496542163W00000X
CA00133082163WC0400X
CA190175806163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management