MEDICARE: KELCIE CLINKENBEARD MYTP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174H00000X	Health Educator

General Provider Information

NPI Number	:	1700627353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELCIE CLINKENBEARD MYTP

Provider Business Mailing Address
First Line	:	1546 E JEANINE DR
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85284-3372
Country	:	US
Telephone Number	:	317-385-5589
Fax Number	:

Provider Business Practice Location Address
First Line	:	1546 E JEANINE DR
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85284-3372
Country	:	US
Telephone Number	:	317-385-5589
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2024
Last Update Date	:	06/05/2024

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