Healthcare Provider Details

I. General information

NPI: 1639489727
Provider Name (Legal Business Name): KELLI KAYE HERNANDEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLI KAYE WILSON PA-C

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S TUSTIN ST
ORANGE CA
92866-3425
US

IV. Provider business mailing address

700 S TUSTIN ST
ORANGE CA
92866-3425
US

V. Phone/Fax

Practice location:
  • Phone: 714-922-4100
  • Fax:
Mailing address:
  • Phone: 714-922-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA21159
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA21159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: