Basic Information
| Provider Information | |||||||||
| NPI: | 1346642030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | KARISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 SANTA ANITA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917311611 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 867 N FAIR OAKS AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911033050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267986793 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2014 | ||||||||
| LastUpdateDate: | 11/02/2018 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.