Healthcare Provider Details

I. General information

NPI: 1659764124
Provider Name (Legal Business Name): KALAN ANN KELCH AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14445 W MCDOWELL RD STE A104
GOODYEAR AZ
85395-2518
US

IV. Provider business mailing address

14445 W MCDOWELL RD STE A104
GOODYEAR AZ
85395-2518
US

V. Phone/Fax

Practice location:
  • Phone: 480-561-5000
  • Fax: 480-984-4066
Mailing address:
  • Phone: 480-561-5000
  • Fax: 480-984-4066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number221426
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number221426
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: