MEDICARE: KELLY BALL

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	95004819	CA

General Provider Information

NPI Number	:	1902343833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY BALL

Provider Business Mailing Address
First Line	:	PO BOX 232410
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92193-2410
Country	:	US
Telephone Number	:	858-249-6748
Fax Number	:	619-543-3183

Provider Business Practice Location Address
First Line	:	4074 FALCON ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-1857
Country	:	US
Telephone Number	:	206-355-5967
Fax Number	:

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

Provider Enumeration Date	:	01/30/2017
Last Update Date	:	05/22/2017

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Directions to “ KELLY BALL ” Practice Location

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