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NPI Code Detail

MEDICARE: KELLY THEODORE PMHNP, FNP

MEDICARE: KELLY THEODORE PMHNP, FNP
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner6467WI
2363L00000XNurse Practitioner6467WI

General Provider Information

NPI Number : 1821472226
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY THEODORE PMHNP, FNP
Provider Business Mailing Address
First Line : 4800 N SCOTTSDALE RD STE 2500
Second Line :
City : SCOTTSDALE
State : AZ
Zip : 85251-7630
Country : US
Telephone Number : 262-999-3495
Fax Number :
Provider Business Practice Location Address
First Line : 111 E WISCONSIN AVE STE 1500
Second Line :
City : MILWAUKEE
State : WI
Zip : 53202-4808
Country : US
Telephone Number : 262-999-3495
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/15/2015
Last Update Date : 05/22/2026

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Directions to “ KELLY THEODORE PMHNP, FNP” Practice Location

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