Healthcare Provider Details

I. General information

NPI: 1013394865
Provider Name (Legal Business Name): KELLY ANN YOUNG RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 EL CAJON BLVD
EL CAJON CA
92020-5703
US

IV. Provider business mailing address

5651 COPLEY DR
SAN DIEGO CA
92111-7903
US

V. Phone/Fax

Practice location:
  • Phone: 858-499-2600
  • Fax:
Mailing address:
  • Phone: 858-499-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number995892
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: