Healthcare Provider Details

I. General information

NPI: 1114703725
Provider Name (Legal Business Name): TRACY KELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5499
US

IV. Provider business mailing address

14857 N DEERSKIN DR
FOUNTAIN HILLS AZ
85268-2504
US

V. Phone/Fax

Practice location:
  • Phone: 480-301-4142
  • Fax:
Mailing address:
  • Phone: 480-330-5969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License NumberRN115809
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: