Basic Information
| Provider Information | |||||||||
| NPI: | 1295784130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYATT | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 332 S JUNIPER ST | ||||||||
| Address2: | SUITE100 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920254941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662282236 | ||||||||
| FaxNumber: | 7607373430 | ||||||||
| Practice Location | |||||||||
| Address1: | 31537 RANCHO PUEBLO RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925924841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513032277 | ||||||||
| FaxNumber: | 9513036432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A80960 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | FU294Z | 01 | MEDICARE PTAN | OTHER |