Healthcare Provider Details

I. General information

NPI: 1548902109
Provider Name (Legal Business Name): KELI NICOLE PRYOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE PRYOR

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8836 S VERMONT AVE
LOS ANGELES CA
90044-4832
US

IV. Provider business mailing address

4712 ADMIRALTY WAY # 923
MARINA DEL REY CA
90292-6905
US

V. Phone/Fax

Practice location:
  • Phone: 213-451-4370
  • Fax:
Mailing address:
  • Phone: 310-486-1630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105466
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: