Provider Demographics
NPI:1063171635
Name:KELLEY, KATY-ANN (RN)
Entity type:Individual
Prefix:
First Name:KATY-ANN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 AGNES WAY
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-3904
Mailing Address - Country:US
Mailing Address - Phone:925-997-0106
Mailing Address - Fax:
Practice Address - Street 1:2633 E 27TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-1912
Practice Address - Country:US
Practice Address - Phone:510-535-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95146793163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health