1710047220 NPI number — MRS. ROSEMARY TILMON-KELLUM PA-C

Table of content: MRS. ROSEMARY TILMON-KELLUM PA-C (NPI 1710047220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710047220 NPI number — MRS. ROSEMARY TILMON-KELLUM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILMON-KELLUM
Provider First Name:
ROSEMARY
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLUM
Provider Other First Name:
ROSEMARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1710047220
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1250 BELLFLOWER BLVD
Provider Second Line Business Mailing Address:
STUDENT HEALTH CENTER
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90840
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-985-4771
Provider Business Mailing Address Fax Number:
562-985-1644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 BELLFLOWER BLVD.
Provider Second Line Business Practice Location Address:
STUDENT HEALTH CENTER
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-985-4771
Provider Business Practice Location Address Fax Number:
562-985-1644
Provider Enumeration Date:
12/12/2006

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: 363AM0700X , with the licence number:  13327 , 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)





Copyright © 2007-2025 www.npivalidator.com