Provider Demographics
NPI:1841220860
Name:FREEBORN, KELLIE (NP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:FREEBORN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:FREEBORN DUFFIELD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 12170
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2170
Mailing Address - Country:US
Mailing Address - Phone:877-818-6102
Mailing Address - Fax:
Practice Address - Street 1:5555 GROSSMONT CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-644-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF12491207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN581933Medicaid
P61247Medicare UPIN
CARN581933Medicaid