1134229735 NPI number — DR. KELLY ANN NIX D.P.M.

Table of content: DR. KELLY ANN NIX D.P.M. (NPI 1134229735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134229735 NPI number — DR. KELLY ANN NIX D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIX
Provider First Name:
KELLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134229735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3323 OXFORD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95117-3040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-243-1710
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15047 LOS GATOS BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LOS GATOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95032-2054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-356-2774
Provider Business Practice Location Address Fax Number:
408-356-2140
Provider Enumeration Date:
09/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  E4341 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)