Healthcare Provider Details

I. General information

NPI: 1336307495
Provider Name (Legal Business Name): COURTNEY ANN KELLER PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COURTNEY ANN KONDOS/MERCK APRN-CNS

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9165 W THUNDERBIRD RD SUITE 201
PEORIA AZ
85381-4847
US

IV. Provider business mailing address

9165 W THUNDERBIRD RD SUITE 201
PEORIA AZ
85381-4847
US

V. Phone/Fax

Practice location:
  • Phone: 623-876-8420
  • Fax: 623-285-2626
Mailing address:
  • Phone: 623-876-8420
  • Fax: 623-285-2626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP7558
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number46
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number46
License Number StateND
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN173592
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: