Healthcare Provider Details

I. General information

NPI: 1326213554
Provider Name (Legal Business Name): AMANDA KELLY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CALIFORNIA ST SUITE 100
SAN FRANCISCO CA
94109-4586
US

IV. Provider business mailing address

3 HARBOR DR STE 111
SAUSALITO CA
94965-1491
US

V. Phone/Fax

Practice location:
  • Phone: 415-386-8406
  • Fax: 415-386-5388
Mailing address:
  • Phone: 415-683-2988
  • Fax: 415-683-2980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number492432
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: