Healthcare Provider Details

I. General information

NPI: 1194634840
Provider Name (Legal Business Name): MYAH KELLAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 DEL PASO RD
SACRAMENTO CA
95834-9719
US

IV. Provider business mailing address

8939 UPBEAT WAY
ELK GROVE CA
95757-5535
US

V. Phone/Fax

Practice location:
  • Phone: 279-895-5651
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: