Provider Demographics
NPI:1932120516
Name:HUMPHREY, KELLI (NP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92652-0449
Mailing Address - Country:US
Mailing Address - Phone:949-233-5943
Mailing Address - Fax:949-715-1087
Practice Address - Street 1:1071 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-1934
Practice Address - Country:US
Practice Address - Phone:949-233-5943
Practice Address - Fax:949-715-1087
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11464363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP07445Medicare UPIN