Healthcare Provider Details

I. General information

NPI: 1689467003
Provider Name (Legal Business Name): KEITH MICHAEL KELLEY APRN-RNP, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2048 N WOODBURNE PL
CHANDLER AZ
85224-1179
US

IV. Provider business mailing address

2048 N WOODBURNE PL
CHANDLER AZ
85224-1179
US

V. Phone/Fax

Practice location:
  • Phone: 480-292-1140
  • Fax:
Mailing address:
  • Phone: 480-292-1140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number327863
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN196998
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: