Healthcare Provider Details

I. General information

NPI: 1669939088
Provider Name (Legal Business Name): KELLY JACQUELIN MCWAID
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 SEABRIGHT AVE
SANTA CRUZ CA
95062-2597
US

IV. Provider business mailing address

403 WOODROW AVE
SANTA CRUZ CA
95060-6419
US

V. Phone/Fax

Practice location:
  • Phone: 831-429-3410
  • Fax: 831-429-3450
Mailing address:
  • Phone: 831-713-6384
  • Fax: 831-515-7971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number469687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: