Provider Demographics
NPI:1982004792
Name:BORMAN, KELLY FONS (NP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:FONS
Last Name:BORMAN
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 1:4249 STERN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-4226
Mailing Address - Country:US
Mailing Address - Phone:248-762-1963
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD # 54
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-7844
Practice Address - Fax:323-361-8767
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA740170163W00000X
CA21393363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse