Healthcare Provider Details

I. General information

NPI: 1861944829
Provider Name (Legal Business Name): KELSEY SCATTERGOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 PIER AVE STE B #125
HERMOSA BEACH CA
90254-3943
US

IV. Provider business mailing address

703 PIER AVE STE B #125
HERMOSA BEACH CA
90254-3943
US

V. Phone/Fax

Practice location:
  • Phone: 609-238-4178
  • Fax:
Mailing address:
  • Phone: 609-238-4178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95004400
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: