Provider Demographics
NPI:1013091958
Name:KINSLEY, KELLY A (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:KINSLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 S RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-6821
Mailing Address - Country:US
Mailing Address - Phone:707-822-3376
Mailing Address - Fax:707-822-5053
Practice Address - Street 1:4715 VALLEY EAST BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-3584
Practice Address - Country:US
Practice Address - Phone:707-822-3376
Practice Address - Fax:707-822-5053
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77600207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF22735Medicare UPIN
CA00G776001Medicare Oscar/Certification