Provider Demographics
NPI:1851171904
Name:IBARRA, KELLY O (BA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:O
Last Name:IBARRA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:O
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:3031 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3033
Mailing Address - Country:US
Mailing Address - Phone:323-373-2400
Mailing Address - Fax:
Practice Address - Street 1:3787 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-4203
Practice Address - Country:US
Practice Address - Phone:213-766-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator