Healthcare Provider Details

I. General information

NPI: 1194376855
Provider Name (Legal Business Name): KELSEY CAROLYN DEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 COYLE AVE
CARMICHAEL CA
95608-0306
US

IV. Provider business mailing address

401 WESTACRE RD APT 31
WEST SACRAMENTO CA
95691-2678
US

V. Phone/Fax

Practice location:
  • Phone: 916-537-5374
  • Fax:
Mailing address:
  • Phone: 916-500-8155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: