Healthcare Provider Details

I. General information

NPI: 1962289645
Provider Name (Legal Business Name): KELLY ANN SOMMERS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8741 ALDEN DR
LOS ANGELES CA
90048-3692
US

IV. Provider business mailing address

4761 DON RICARDO DR
LOS ANGELES CA
90008-2812
US

V. Phone/Fax

Practice location:
  • Phone: 310-652-2744
  • Fax:
Mailing address:
  • Phone: 713-838-5996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA63298
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: