Provider Demographics
NPI:1255899498
Name:VILLANUEVA, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:VILLANUEVA
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:PO BOX 4436
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617-4436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2629 GRAMBLING CT
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-2576
Practice Address - Country:US
Practice Address - Phone:530-400-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA574700009253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care