Healthcare Provider Details

I. General information

NPI: 1548451685
Provider Name (Legal Business Name): KAREN RUTH KELLEHER LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 LUCKY LANE
LOTUS CA
95651-0564
US

IV. Provider business mailing address

PO BOX 564 4620 LUCKY LANE
LOTUS CA
95651-0564
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-1255
  • Fax:
Mailing address:
  • Phone: 530-626-1255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN121814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: