Provider Demographics
NPI:1053830851
Name:BOOTH, KELLEY C (NP)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:C
Last Name:BOOTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-204-8290
Mailing Address - Fax:510-506-7725
Practice Address - Street 1:2850 TELEGRAPH AVE STE 120
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1159
Practice Address - Country:US
Practice Address - Phone:510-204-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007295363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95007295OtherSTATE MEDICAL LICENSE
CANP95007295OtherSTATE MEDICAL LICENSE