Healthcare Provider Details

I. General information

NPI: 1619973930
Provider Name (Legal Business Name): KELLY MARCUM NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2931 S HWY 260
OVERGAARD AZ
85933
US

IV. Provider business mailing address

2200 E SHOW LOW LAKE RD
SHOW LOW AZ
85901
US

V. Phone/Fax

Practice location:
  • Phone: 928-536-3616
  • Fax: 928-536-3615
Mailing address:
  • Phone: 928-537-6978
  • Fax: 928-537-4205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN036514
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: