Provider Demographics
NPI:1245828672
Name:KHAMKONGSAY, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KHAMKONGSAY
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 1:9064 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-1813
Mailing Address - Country:US
Mailing Address - Phone:818-352-8333
Mailing Address - Fax:
Practice Address - Street 1:9064 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-1813
Practice Address - Country:US
Practice Address - Phone:818-352-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015584363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner