Healthcare Provider Details

I. General information

NPI: 1235029653
Provider Name (Legal Business Name): PATRICK GLENN KELLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 ROSIN CT
SACRAMENTO CA
95834-1646
US

IV. Provider business mailing address

3780 ROSIN CT
SACRAMENTO CA
95834-1646
US

V. Phone/Fax

Practice location:
  • Phone: 916-767-1893
  • Fax:
Mailing address:
  • Phone: 916-767-1893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: