Healthcare Provider Details

I. General information

NPI: 1790450229
Provider Name (Legal Business Name): ASHLEY KELEPOLO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/16/2021
Certification Date: 08/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N 13TH W
SAINT JOHNS AZ
85936-4986
US

IV. Provider business mailing address

714 W AIRPORT RD
SPRINGERVILLE AZ
85938-5013
US

V. Phone/Fax

Practice location:
  • Phone: 928-337-3000
  • Fax:
Mailing address:
  • Phone: 480-258-0481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number262356
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF07211457
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: