Healthcare Provider Details

I. General information

NPI: 1780014175
Provider Name (Legal Business Name): KELLEY HILTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2013
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 DOYLE PARK DR STE 101
SANTA ROSA CA
95405-4562
US

IV. Provider business mailing address

525 DOYLE PARK DR STE 101
SANTA ROSA CA
95405-4562
US

V. Phone/Fax

Practice location:
  • Phone: 707-525-6620
  • Fax: 707-693-7040
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62928
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number027030
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT469
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: