MEDICARE: KELSEY SAN MIGUEL LOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	95029835	CA

General Provider Information

NPI Number	:	1023847365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY SAN MIGUEL LOR

Provider Business Mailing Address
First Line	:	7483 JERSEY ST
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91708-9134
Country	:	US
Telephone Number	:	909-851-2129
Fax Number	:

Provider Business Practice Location Address
First Line	:	7483 JERSEY ST
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91708-9134
Country	:	US
Telephone Number	:	909-851-2129
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2024
Last Update Date	:	07/26/2024

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Directions to “ KELSEY SAN MIGUEL LOR ” Practice Location

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