Provider Demographics
NPI:1922156397
Name:SHANNON, KELLI KAZLAUSKAS (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:KAZLAUSKAS
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5651 COPLEY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7903
Mailing Address - Country:US
Mailing Address - Phone:858-262-6344
Mailing Address - Fax:
Practice Address - Street 1:10670 WEXFORD ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-3940
Practice Address - Country:US
Practice Address - Phone:858-499-2702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA125621207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology