Healthcare Provider Details

I. General information

NPI: 1336201219
Provider Name (Legal Business Name): THERESA KELSO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5616 E MAIN ST
MESA AZ
85205-8813
US

IV. Provider business mailing address

5616 E MAIN ST
MESA AZ
85205-8813
US

V. Phone/Fax

Practice location:
  • Phone: 480-396-3222
  • Fax: 480-396-2298
Mailing address:
  • Phone: 480-396-3222
  • Fax: 480-396-2298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN095337
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: