Provider Demographics
NPI:1669939088
Name:MCWAID, KELLY JACQUELIN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JACQUELIN
Last Name:MCWAID
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 1:403 WOODROW AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-6419
Mailing Address - Country:US
Mailing Address - Phone:831-713-6384
Mailing Address - Fax:831-515-7971
Practice Address - Street 1:1320 SEABRIGHT AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2597
Practice Address - Country:US
Practice Address - Phone:831-429-3410
Practice Address - Fax:831-429-3450
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA469687163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool