Provider Demographics
NPI:1134553381
Name:PHAN, KELLY NGUYEN (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NGUYEN
Last Name:PHAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 ORANGEFAIR MALL
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-3038
Mailing Address - Country:US
Mailing Address - Phone:714-870-6116
Mailing Address - Fax:714-870-9038
Practice Address - Street 1:233 ORANGEFAIR MALL
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-3038
Practice Address - Country:US
Practice Address - Phone:714-870-6116
Practice Address - Fax:714-870-9038
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA376832251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics