Provider Demographics
NPI:1669792107
Name:KELLY, SHANNON (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 CUTTER WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-4437
Mailing Address - Country:US
Mailing Address - Phone:504-319-1574
Mailing Address - Fax:
Practice Address - Street 1:270 MASONIC AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-4417
Practice Address - Country:US
Practice Address - Phone:504-319-1574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1003342080P0207X
CA100334207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine