Provider Demographics
NPI:1265886071
Name:MORRILL, KELLY (MSN, RN, FNP-BC, CEN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MORRILL
Suffix:
Gender:F
Credentials:MSN, RN, FNP-BC, CEN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN, FNP-BC, CEN
Mailing Address - Street 1:1432 ANSLEY DR
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-8450
Mailing Address - Country:US
Mailing Address - Phone:210-878-7220
Mailing Address - Fax:
Practice Address - Street 1:1133 E STANLEY BLVD
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4200
Practice Address - Country:US
Practice Address - Phone:925-373-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA724598163WE0003X
CA95004710363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency