Healthcare Provider Details

I. General information

NPI: 1710549258
Provider Name (Legal Business Name): KELLIE A. WILLIAMS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2019
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SUPERIOR AVE STE 305
NEWPORT BEACH CA
92663-3660
US

IV. Provider business mailing address

500 SUPERIOR AVE STE 305
NEWPORT BEACH CA
92663-3660
US

V. Phone/Fax

Practice location:
  • Phone: 949-644-2722
  • Fax: 949-650-3135
Mailing address:
  • Phone: 949-644-2722
  • Fax: 949-650-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95036842
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: