Healthcare Provider Details

I. General information

NPI: 1477236727
Provider Name (Legal Business Name): ALEXANDRA KRISTINE KELLOGG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6136 LAKE MURRAY BLVD
LA MESA CA
91942-2502
US

IV. Provider business mailing address

5560 SHASTA LN APT 44
LA MESA CA
91942-4410
US

V. Phone/Fax

Practice location:
  • Phone: 877-693-6266
  • Fax:
Mailing address:
  • Phone: 619-840-4756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65973
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: