Provider Demographics
NPI:1871096552
Name:PHIPPS, KELLY ALASTAIR (CLEC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ALASTAIR
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:CLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 GREENBERRY LN
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1226
Mailing Address - Country:US
Mailing Address - Phone:415-412-5104
Mailing Address - Fax:
Practice Address - Street 1:818 GREENBERRY LN
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1226
Practice Address - Country:US
Practice Address - Phone:415-412-5104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2017DONA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula