Healthcare Provider Details

I. General information

NPI: 1255199717
Provider Name (Legal Business Name): KELLY E KECK NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY E FLYNN

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 CAMPUS POINT DR
LA JOLLA CA
92037-1300
US

IV. Provider business mailing address

2646 ILLION ST
SAN DIEGO CA
92110-2362
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-7000
  • Fax:
Mailing address:
  • Phone: 303-386-5428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number95029214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: