Healthcare Provider Details

I. General information

NPI: 1578486361
Provider Name (Legal Business Name): KELLY LAMONT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13924 MARQUESAS WAY
MARINA DEL REY CA
90292-6041
US

IV. Provider business mailing address

13924 MARQUESAS WAY
MARINA DEL REY CA
90292-6041
US

V. Phone/Fax

Practice location:
  • Phone: 424-394-5430
  • Fax: 424-394-5430
Mailing address:
  • Phone: 424-394-5430
  • Fax: 424-394-5430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number652472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: