Healthcare Provider Details

I. General information

NPI: 1912823618
Provider Name (Legal Business Name): KIERSTEN MACKENZIE PROEHL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 N DYSART RD STE G127
AVONDALE AZ
85392-1011
US

IV. Provider business mailing address

3400 N DYSART RD STE G127
AVONDALE AZ
85392-1011
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-0323
  • Fax: 623-322-0757
Mailing address:
  • Phone: 623-322-0323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number11872
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: