Healthcare Provider Details

I. General information

NPI: 1467995233
Provider Name (Legal Business Name): TRISHA KELLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN PATRICIA KELLEY DUNCAN

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 09/29/2023
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 E CHEVY CHASE DR STE. 140
GLENDALE CA
91206
US

IV. Provider business mailing address

1560 E CHEVY CHASE DR STE. 140
GLENDALE CA
91206
US

V. Phone/Fax

Practice location:
  • Phone: 888-228-7425
  • Fax: 818-790-1778
Mailing address:
  • Phone: 832-474-2680
  • Fax: 818-790-1778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA152033
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: