Healthcare Provider Details

I. General information

NPI: 1174981021
Provider Name (Legal Business Name): KELLY MORAY NEWMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2016
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 MORENA BLVD
SAN DIEGO CA
92110-3703
US

IV. Provider business mailing address

8775 AERO DR STE 132
SAN DIEGO CA
92123-1779
US

V. Phone/Fax

Practice location:
  • Phone: 619-275-8000
  • Fax:
Mailing address:
  • Phone: 858-609-8742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: