Healthcare Provider Details

I. General information

NPI: 1740896646
Provider Name (Legal Business Name): KELLY ANNE BREWER RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 09/17/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N. STATE ROUTE 89 CPAP CLINIC
PRESCOTT AZ
86313
US

IV. Provider business mailing address

500 N STATE ROUTE 89
PRESCOTT AZ
86313-5001
US

V. Phone/Fax

Practice location:
  • Phone: 928-776-6047
  • Fax:
Mailing address:
  • Phone: 928-776-6047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number004041
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: