Healthcare Provider Details

I. General information

NPI: 1518454222
Provider Name (Legal Business Name): KELLY GLEASON MURPHY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21115 NEWPORT COAST DR
NEWPORT BEACH CA
92657-1122
US

IV. Provider business mailing address

PO BOX 3699
NEWPORT BEACH CA
92659-8699
US

V. Phone/Fax

Practice location:
  • Phone: 949-557-0728
  • Fax: 949-557-0731
Mailing address:
  • Phone: 657-241-3600
  • Fax: 657-241-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017644
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95012557
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95194299
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number041387962
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: