Healthcare Provider Details

I. General information

NPI: 1982004792
Provider Name (Legal Business Name): KELLY FONS BORMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD # 54
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

4249 STERN AVE
SHERMAN OAKS CA
91423-4226
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-7844
  • Fax: 323-361-8767
Mailing address:
  • Phone: 248-762-1963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number21393
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number740170
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: