Healthcare Provider Details

I. General information

NPI: 1790718690
Provider Name (Legal Business Name): LYNETTA J KELLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 E 7TH ST
LONG BEACH CA
90822-5201
US

IV. Provider business mailing address

5901 E 7TH ST
LONG BEACH CA
90822-5201
US

V. Phone/Fax

Practice location:
  • Phone: 562-826-8000
  • Fax: 562-826-8001
Mailing address:
  • Phone: 562-826-8000
  • Fax: 562-826-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number416746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: