Healthcare Provider Details

I. General information

NPI: 1851752224
Provider Name (Legal Business Name): NICOLE ANGELA KELLY-GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 N 4TH ST
FLAGSTAFF AZ
86004-1816
US

IV. Provider business mailing address

PO BOX 1231
TUCSON AZ
85702-1231
US

V. Phone/Fax

Practice location:
  • Phone: 928-853-2360
  • Fax: 928-853-2360
Mailing address:
  • Phone: 520-670-3909
  • Fax: 520-309-2560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-15933
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: