Healthcare Provider Details

I. General information

NPI: 1851720189
Provider Name (Legal Business Name): KELLY E BREEN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 N 3RD ST
PHOENIX AZ
85012-2331
US

IV. Provider business mailing address

750 W BASELINE RD APT 2142
TEMPE AZ
85283-5937
US

V. Phone/Fax

Practice location:
  • Phone: 602-257-9339
  • Fax: 602-285-6533
Mailing address:
  • Phone: 480-820-5422
  • Fax: 480-775-4938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP5301
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: