Provider Demographics
NPI:1013420801
Name:SCOTT, KELLY MARIE (PMHNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6599
Mailing Address - Country:US
Mailing Address - Phone:619-234-2158
Mailing Address - Fax:619-487-9739
Practice Address - Street 1:2630 1ST AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6599
Practice Address - Country:US
Practice Address - Phone:619-795-8746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0216030363LP0808X
CA95015026363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health