Healthcare Provider Details

I. General information

NPI: 1528534005
Provider Name (Legal Business Name): KELLY DIANE SHEEHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W TOWN AND COUNTRY RD STE 1600
ORANGE CA
92868
US

IV. Provider business mailing address

3343 4TH AVE APT 104
SAN DIEGO CA
92103-5703
US

V. Phone/Fax

Practice location:
  • Phone: 844-310-2247
  • Fax:
Mailing address:
  • Phone: 508-237-3808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2283832
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95010297
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2283832
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: