Provider Demographics
NPI:1750072203
Name:LE, KELLIE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:LE
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 1:1025 B ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4107
Mailing Address - Country:US
Mailing Address - Phone:510-733-0288
Mailing Address - Fax:
Practice Address - Street 1:1025 B ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4107
Practice Address - Country:US
Practice Address - Phone:510-733-0288
Practice Address - Fax:510-733-6273
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19758171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist