Healthcare Provider Details

I. General information

NPI: 1043584816
Provider Name (Legal Business Name): KEVIN AUSTIN MCKELLAR R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2012
Last Update Date: 02/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 THE ALAMEDA
SAN JOSE CA
95126-1136
US

IV. Provider business mailing address

1254 LERIDA WAY
PACIFICA CA
94044-3634
US

V. Phone/Fax

Practice location:
  • Phone: 408-261-7777
  • Fax: 408-254-9960
Mailing address:
  • Phone: 650-922-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number784443
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: