Provider Demographics
NPI:1295305050
Name:GILBERT, KELLY GENE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:GENE
Last Name:GILBERT
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 1:3437 WILL SCARLET WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-9299
Mailing Address - Country:US
Mailing Address - Phone:209-774-6918
Mailing Address - Fax:
Practice Address - Street 1:300 E 15TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6217
Practice Address - Country:US
Practice Address - Phone:209-386-1096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA714814164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse