Healthcare Provider Details

I. General information

NPI: 1770113623
Provider Name (Legal Business Name): KELLY WATKINS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 SUPERIOR AVE
NEWPORT BEACH CA
92663-3637
US

IV. Provider business mailing address

325 ESTANCIA
IRVINE CA
92602-1106
US

V. Phone/Fax

Practice location:
  • Phone: 949-764-7398
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95012178
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number95012178
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number95012178
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: