Healthcare Provider Details

I. General information

NPI: 1851753255
Provider Name (Legal Business Name): KELLY RAE HARRIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16515 S 40TH ST STE 135
PHOENIX AZ
85048-0560
US

IV. Provider business mailing address

20401 N 73RD ST STE 230
SCOTTSDALE AZ
85255-4153
US

V. Phone/Fax

Practice location:
  • Phone: 480-556-0446
  • Fax: 480-556-0447
Mailing address:
  • Phone: 480-556-0446
  • Fax: 480-556-0447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN173398
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP8587
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: