Healthcare Provider Details

I. General information

NPI: 1710801212
Provider Name (Legal Business Name): ALYSSA MICHELLE KELLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 3RD ST STE C
LAKE ELSINORE CA
92530-2748
US

IV. Provider business mailing address

1404 EVERTON PL
RIVERSIDE CA
92507-4439
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-5354
  • Fax:
Mailing address:
  • Phone: 760-906-2159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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: