Healthcare Provider Details

I. General information

NPI: 1609229376
Provider Name (Legal Business Name): MRS. KELLY JEAN GARNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 PALMAS NORTE
FALLBROOK CA
92028-2541
US

IV. Provider business mailing address

126 PALMAS NORTE
FALLBROOK CA
92028-2541
US

V. Phone/Fax

Practice location:
  • Phone: 805-490-1538
  • Fax:
Mailing address:
  • Phone: 805-490-1538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: