Healthcare Provider Details

I. General information

NPI: 1326020397
Provider Name (Legal Business Name): DANA LYNNE KELLY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 EAST 31ST ST
OAKLAND CA
94602-1018
US

IV. Provider business mailing address

4301 NORTH STAR WAY
MODESTO CA
95356
US

V. Phone/Fax

Practice location:
  • Phone: 209-342-2300
  • Fax: 209-524-4240
Mailing address:
  • Phone: 209-342-2300
  • Fax: 209-524-4240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SE0003X
TaxonomyEmergency Clinical Nurse Specialist
License NumberPA13877
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: