Healthcare Provider Details

I. General information

NPI: 1508158288
Provider Name (Legal Business Name): KALIE NICOLE LI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KALIE NICOLE BRENNEMAN D.O.

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 PENNSYLVANIA AVE STE 300
FAIRFIELD CA
94533-3550
US

IV. Provider business mailing address

1860 PENNSYLVANIA AVE STE 300
FAIRFIELD CA
94533-3550
US

V. Phone/Fax

Practice location:
  • Phone: 707-646-4100
  • Fax: 707-646-4101
Mailing address:
  • Phone: 707-646-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20A14112
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number63056
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: