Healthcare Provider Details

I. General information

NPI: 1295041507
Provider Name (Legal Business Name): MRS. KELLY M JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS KELLY M DUNAWAY

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5324 E WASHINGTON ST
PHOENIX AZ
85034-2144
US

IV. Provider business mailing address

29774 N 69TH AVE
PEORIA AZ
85383-3173
US

V. Phone/Fax

Practice location:
  • Phone: 602-732-3384
  • Fax:
Mailing address:
  • Phone: 219-808-0293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26020635A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS017785
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: