Healthcare Provider Details

I. General information

NPI: 1366476004
Provider Name (Legal Business Name): KELLY LIME BRANNAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14155 N 83RD AVE STE 122
PEORIA AZ
85381-5640
US

IV. Provider business mailing address

13014 N 23RD ST
PHOENIX AZ
85022-5124
US

V. Phone/Fax

Practice location:
  • Phone: 623-773-1161
  • Fax:
Mailing address:
  • Phone: 623-703-2339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2701
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: