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General NPI Number Information
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NPI Number | 1982004792
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Entity Type | Individual
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Provider Name | KELLY FONS BORMAN NP
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Gender | Female
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Dates
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Enumeration Date | 08/28/2014
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Last Update Date | 06/18/2015
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Provider Practice Location Address
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Address Line | 4650 W SUNSET BLVD # 54
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City | LOS ANGELES
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State | CA
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Zip | 90027-6062
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Country | US
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Telephone | 323-361-7844
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Fax | 323-361-8767
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Provider Business Mailing Address
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Address Line | 4249 STERN AVE
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City | SHERMAN OAKS
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State | CA
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Zip | 91423-4226
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Country | US
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Telephone | 248-762-1963
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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 | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 21393
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 740170
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License Number State | CA
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