1255091773 NPI number — MISS KELSEY ELIZABETH CORBETT DACM

Table of content: MISS KELSEY ELIZABETH CORBETT DACM (NPI 1255091773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255091773 NPI number — MISS KELSEY ELIZABETH CORBETT DACM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORBETT
Provider First Name:
KELSEY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
DACM
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:
1255091773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
786 DEL RIO AVE UNIT 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENCINITAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92024-2321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-678-8977
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
523 ENCINITAS BLVD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENCINITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92024-3739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-678-8977
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/23/2021

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: 171100000X , with the licence number:  18634 , 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)





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