Basic Information
| Provider Information | |||||||||
| NPI: | 1013109792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGERICH | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | VA SAN DIEGO HEALTHCARE SYSTEM | ||||||||
| Address2: | 3350 LA JOLLA VILLAGE DRIVE | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | VA SAN DIEGO HEALTHCARE SYSTEM | ||||||||
| Address2: | 3350 LA JOLLA VILLAGE DRIVE | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 08/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A113020 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.