Provider Demographics
NPI:1265085468
Name:SAMPLES, KELLI (RN)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:SAMPLES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6323 ECHO HILLS LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5770 RIVERSIDE DR., BLDG 601
Practice Address - Street 2:752 MEDICAL SQUADRON
Practice Address - City:MARCH ARB
Practice Address - State:CA
Practice Address - Zip Code:92518
Practice Address - Country:US
Practice Address - Phone:951-655-5167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95090882163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice