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General NPI Number Information
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NPI Number | 1508389701
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Entity Type | Individual
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Provider Name | MAN KELLIE LY FNP
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Gender | Female
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Dates
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Enumeration Date | 07/19/2017
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Last Update Date | 10/01/2024
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Provider Practice Location Address
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Address Line | 3106 W BEVERLY BLVD
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City | MONTEBELLO
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State | CA
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Zip | 90640-2217
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Country | US
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Telephone | 323-728-1274
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Fax |
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Provider Business Mailing Address
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Address Line | 711 W VALLEY VIEW DR
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City | FULLERTON
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State | CA
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Zip | 92835-4077
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Country | US
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Telephone | 626-390-2908
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP2201X
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Taxonomy Name | Ambulatory Care Registered Nurse
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License Number | 615128
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 95032279
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License Number State | CA
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