Basic Information
| Provider Information | |||||||||
| NPI: | 1770822116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | HARUKA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2350 W EL CAMINO REAL FL 2 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940406203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102045600 | ||||||||
| FaxNumber: | 5105067722 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 MILVIA ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102045600 | ||||||||
| FaxNumber: | 5105067722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2013 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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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 | 363LP2300X | 95007416 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | NP95007416 | 01 | CA | STATE MEDICAL LICENSE | OTHER |