Healthcare Provider Details

I. General information

NPI: 1316523459
Provider Name (Legal Business Name): KELLIE JO ENDERSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27450 YNEZ RD
TEMECULA CA
92591-4671
US

IV. Provider business mailing address

27450 YNEZ RD
TEMECULA CA
92591-4671
US

V. Phone/Fax

Practice location:
  • Phone: 951-383-4333
  • Fax: 951-506-2361
Mailing address:
  • Phone: 951-383-4333
  • Fax: 951-506-2361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA162928
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: