Healthcare Provider Details

I. General information

NPI: 1942152749
Provider Name (Legal Business Name): KELLIE SNYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W BROWN RD STE 1011
MESA AZ
85201-3222
US

IV. Provider business mailing address

10121 E GAMMA AVE
MESA AZ
85212-9221
US

V. Phone/Fax

Practice location:
  • Phone: 360-280-5149
  • Fax:
Mailing address:
  • Phone: 360-280-5149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number309482
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number309482
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: