Basic Information
| Provider Information | |||||||||
| NPI: | 1588878623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72780 COUNTRY CLUB DR | ||||||||
| Address2: | BLDG B 203 | ||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922704126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606743847 | ||||||||
| FaxNumber: | 7606743845 | ||||||||
| Practice Location | |||||||||
| Address1: | 72780 COUNTRY CLUB DR | ||||||||
| Address2: | BLDG B 203 | ||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922704126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606743847 | ||||||||
| FaxNumber: | 7606743845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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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 | 363LA2100X | 300549 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.