Provider Demographics
NPI:1356995492
Name:KELLAM, DARNELL V JR
Entity type:Individual
Prefix:MR
First Name:DARNELL
Middle Name:V
Last Name:KELLAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 MISSION AVE APT 35
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-3161
Mailing Address - Country:US
Mailing Address - Phone:678-457-1598
Mailing Address - Fax:
Practice Address - Street 1:3410 MISSION AVE APT 35
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-3161
Practice Address - Country:US
Practice Address - Phone:678-457-1598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4692667172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty