Basic Information
| Provider Information | |||||||||
| NPI: | 1780129072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCNICOLL | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | AYNNE | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 B ST | ||||||||
| Address2: | SUITE 1570 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921014501 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3853 ROSECRANS ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196150439 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2016 | ||||||||
| LastUpdateDate: | 12/22/2016 | ||||||||
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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 | 163WP0808X | 95033920 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.