Healthcare Provider Details

I. General information

NPI: 1619100419
Provider Name (Legal Business Name): KELLYN THEODORA PAPPAS L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2009
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8840 WARNER AVE STE 100
FOUNTAIN VALLEY CA
92708-3232
US

IV. Provider business mailing address

82 HAWAII DR
ALISO VIEJO CA
92656-3314
US

V. Phone/Fax

Practice location:
  • Phone: 949-226-2085
  • Fax:
Mailing address:
  • Phone: 949-226-2085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 12779
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: