Healthcare Provider Details

I. General information

NPI: 1578252045
Provider Name (Legal Business Name): KATHERINE ANN KELLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 06/30/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2496 BAUER RD
SAN DIEGO CA
92126
US

IV. Provider business mailing address

2496 BAUER RD
SAN DIEGO CA
92126
US

V. Phone/Fax

Practice location:
  • Phone: 619-881-9011
  • Fax:
Mailing address:
  • Phone: 619-881-9011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101283818
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: