Healthcare Provider Details

I. General information

NPI: 1417282278
Provider Name (Legal Business Name): KELLI NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 E SAN FERNADO STREET
SAN JOSE CA
95112-5569
US

IV. Provider business mailing address

195 E SAN FERNANDO ST
SAN JOSE CA
95112-3503
US

V. Phone/Fax

Practice location:
  • Phone: 408-889-7154
  • Fax: 408-516-9488
Mailing address:
  • Phone: 408-889-7154
  • Fax: 408-516-9488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN241285
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: