Provider Demographics
NPI:1720685639
Name:DU RAND KELLY, JOHNNETTE (MT, CMLDT)
Entity Type:Individual
Prefix:
First Name:JOHNNETTE
Middle Name:
Last Name:DU RAND KELLY
Suffix:
Gender:F
Credentials:MT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 38TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2918
Mailing Address - Country:US
Mailing Address - Phone:949-439-0282
Mailing Address - Fax:
Practice Address - Street 1:116 38TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2918
Practice Address - Country:US
Practice Address - Phone:949-439-0282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-04
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23606225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist