Healthcare Provider Details

I. General information

NPI: 1184603342
Provider Name (Legal Business Name): MARY ELLEN KENWORTHEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MARY ELLEN MERVA

II. Dates (important events)

Enumeration Date: 01/15/2006
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 E THOMAS RD
PHOENIX AZ
85016-8034
US

IV. Provider business mailing address

2525 E ROOSEVELT ST
PHOENIX AZ
85008-4948
US

V. Phone/Fax

Practice location:
  • Phone: 602-470-5000
  • Fax:
Mailing address:
  • Phone: 602-344-1015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberRN043733
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP00853
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: