MEDICARE: ELLEN KLEMAN

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	163W00000X	Registered Nurse	95188599	CA

General Provider Information

NPI Number	:	1538718614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN KLEMAN

Provider Business Mailing Address
First Line	:	2380 CARDINAL DR APT 13
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4105
Country	:	US
Telephone Number	:	920-427-2106
Fax Number	:

Provider Business Practice Location Address
First Line	:	2380 CARDINAL DR APT 13
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4105
Country	:	US
Telephone Number	:	920-427-2106
Fax Number	:

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

Provider Enumeration Date	:	09/10/2019
Last Update Date	:	09/10/2019

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