Healthcare Provider Details

I. General information

NPI: 1699807065
Provider Name (Legal Business Name): KELLY LYNNE KILLEEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N BEDFORD DR STE 103
BEVERLY HILLS CA
90210-4323
US

IV. Provider business mailing address

436 N BEDFORD DR STE 103
BEVERLY HILLS CA
90210-4323
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-8200
  • Fax: 310-278-8230
Mailing address:
  • Phone: 310-278-8200
  • Fax: 310-278-8230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA92060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: