Healthcare Provider Details

I. General information

NPI: 1205420312
Provider Name (Legal Business Name): KELLY LYNN MOUNTAIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26671 ALISO CREED ROAD
ALISO VIEJO CA
92656
US

IV. Provider business mailing address

PO BOX 2218
SUISUN CITY CA
94585-5218
US

V. Phone/Fax

Practice location:
  • Phone: 949-791-3107
  • Fax: 949-791-3184
Mailing address:
  • Phone: 657-241-3600
  • Fax: 657-241-7706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: