Provider Demographics
NPI:1013769561
Name:KEGLEY, KELSIE NOELLE
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:NOELLE
Last Name:KEGLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32384 OLD SAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4199
Mailing Address - Country:US
Mailing Address - Phone:949-370-8440
Mailing Address - Fax:
Practice Address - Street 1:32384 OLD SAGE DR
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-4199
Practice Address - Country:US
Practice Address - Phone:949-370-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95086214163WE0003X
CA95028813363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency