Healthcare Provider Details

I. General information

NPI: 1508389701
Provider Name (Legal Business Name): MAN KELLIE LY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3106 W BEVERLY BLVD
MONTEBELLO CA
90640-2217
US

IV. Provider business mailing address

711 W VALLEY VIEW DR
FULLERTON CA
92835-4077
US

V. Phone/Fax

Practice location:
  • Phone: 323-728-1274
  • Fax:
Mailing address:
  • Phone: 626-390-2908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number615128
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95032279
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: