1396598769 NPI number — M ANGELA DUFFY KELLY ATR 99-076

Table of content: M ANGELA DUFFY KELLY ATR 99-076 (NPI 1396598769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396598769 NPI number — M ANGELA DUFFY KELLY ATR 99-076

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUFFY KELLY
Provider First Name:
M ANGELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATR 99-076
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DUFFY KELLY
Provider Other First Name:
M. ANGELA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ANGELA KELLY PH.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1396598769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
536 N VOLUNTARIO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA BARBARA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93103-2562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-286-5981
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
533 E MICHELTORENA ST STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA BARBARA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93103-2260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-617-1115
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2024

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: 221700000X , with the licence number:  99-076 , 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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