Healthcare Provider Details

I. General information

NPI: 1760525026
Provider Name (Legal Business Name): KELLIE QUAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 WOODMAN AVE
VAN NUYS CA
91401-6310
US

IV. Provider business mailing address

14449 BENEFIT ST APT 5
SHERMAN OAKS CA
91423-4037
US

V. Phone/Fax

Practice location:
  • Phone: 310-770-2842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberR53135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: