Provider Demographics
NPI:1013315563
Name:GWALTNEY, KELLIE (CNM)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:GWALTNEY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 AVENUE OF THE ARTS
Mailing Address - Street 2:APT. #G317
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-1927
Mailing Address - Country:US
Mailing Address - Phone:307-871-9333
Mailing Address - Fax:
Practice Address - Street 1:3400 AVENUE OF THE ARTS
Practice Address - Street 2:APT. #G317
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1927
Practice Address - Country:US
Practice Address - Phone:307-871-9333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235651367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife