Healthcare Provider Details

I. General information

NPI: 1972844371
Provider Name (Legal Business Name): KELLY ANN WILLIAMS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2013
Last Update Date: 12/04/2021
Certification Date: 12/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 PACIFIC COAST HWY
HARBOR CITY CA
90710-3509
US

IV. Provider business mailing address

25825 VERMONT AVE
HARBOR CITY CA
90710-3518
US

V. Phone/Fax

Practice location:
  • Phone: 424-328-2689
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95000585
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number657411-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number852291
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: