Healthcare Provider Details

I. General information

NPI: 1144153719
Provider Name (Legal Business Name): ELIZABETH K KELLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LIZ K KELLEY

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 HOSPITAL RD
SONORA CA
95370-5227
US

IV. Provider business mailing address

2 S GREEN ST
SONORA CA
95370-4618
US

V. Phone/Fax

Practice location:
  • Phone: 209-533-7001
  • Fax: 209-533-7007
Mailing address:
  • Phone: 209-533-7001
  • Fax: 209-533-7007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: