Healthcare Provider Details

I. General information

NPI: 1568274397
Provider Name (Legal Business Name): KYLEEN MCCONNELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E BASELINE RD
PHOENIX AZ
85042-6589
US

IV. Provider business mailing address

325 E BASELINE RD
PHOENIX AZ
85042-6589
US

V. Phone/Fax

Practice location:
  • Phone: 602-243-7277
  • Fax:
Mailing address:
  • Phone: 916-952-0556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11379
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: