Provider Demographics
NPI:1831478742
Name:FEE, KELLY CATHLEEN (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CATHLEEN
Last Name:FEE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:CATHLEEN
Other - Last Name:VANDERBEEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:831 VIA SUERTE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6531
Mailing Address - Country:US
Mailing Address - Phone:949-364-5600
Mailing Address - Fax:949-364-2231
Practice Address - Street 1:831 VIA SUERTE
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6531
Practice Address - Country:US
Practice Address - Phone:949-364-5600
Practice Address - Fax:949-364-2231
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18152363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGW159ZMedicare PIN