Healthcare Provider Details

I. General information

NPI: 1003206004
Provider Name (Legal Business Name): MICHAEL SEAN KELLY NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17601 17TH ST STE 120
TUSTIN CA
92780-1946
US

IV. Provider business mailing address

215 SANTA ISABEL AVE
COSTA MESA CA
92627-1509
US

V. Phone/Fax

Practice location:
  • Phone: 714-769-6090
  • Fax:
Mailing address:
  • Phone: 949-722-7118
  • Fax: 949-722-7119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95001913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: