Healthcare Provider Details

I. General information

NPI: 1912958232
Provider Name (Legal Business Name): TRACI L KELLY R.N., F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 E CORONADO RD
PHOENIX AZ
85004-1525
US

IV. Provider business mailing address

3707 N 7TH ST #305
PHOENIX AZ
85014-5059
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-5678
  • Fax: 602-264-5646
Mailing address:
  • Phone: 602-264-9100
  • Fax: 602-264-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN0604
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: