Provider Demographics
NPI:1124131883
Name:HERING, KELLY J (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:HERING
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:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:MCCLOUD
Mailing Address - State:CA
Mailing Address - Zip Code:96057-0464
Mailing Address - Country:US
Mailing Address - Phone:530-355-5993
Mailing Address - Fax:530-768-2450
Practice Address - Street 1:3184 CHURN CREEK RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2122
Practice Address - Country:US
Practice Address - Phone:530-768-2436
Practice Address - Fax:530-768-2450
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP9446363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN458911Medicaid
CAZZZ03946ZMedicare PIN
CARN458911Medicaid