Healthcare Provider Details

I. General information

NPI: 1558845487
Provider Name (Legal Business Name): KELLY ANNE KIM PNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ANNE HOY

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 4TH ST
SAN FRANCISCO CA
94143-2351
US

IV. Provider business mailing address

3701 WEST RD
LAFAYETTE CA
94549-3704
US

V. Phone/Fax

Practice location:
  • Phone: 925-324-5137
  • Fax:
Mailing address:
  • Phone: 925-324-5137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number95009982
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: