Provider Demographics
NPI:1295295210
Name:NUTTER, KELSI (DPM)
Entity type:Individual
Prefix:
First Name:KELSI
Middle Name:
Last Name:NUTTER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20306 NEW ROCHELLE ST
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-1217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12761 SCHABARUM AVE
Practice Address - Street 2:
Practice Address - City:IRWINDALE
Practice Address - State:CA
Practice Address - Zip Code:91706-6807
Practice Address - Country:US
Practice Address - Phone:626-480-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA5830213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program