Healthcare Provider Details

I. General information

NPI: 1538242367
Provider Name (Legal Business Name): CORNETA E. KELLEY M.A.,CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E FRY BLVD SUITE #5
SIERRA VISTA AZ
85635-2600
US

IV. Provider business mailing address

2160 E FRY BLVD # 310
SIERRA VISTA AZ
85635-2736
US

V. Phone/Fax

Practice location:
  • Phone: 520-459-8258
  • Fax: 520-459-8619
Mailing address:
  • Phone: 520-459-8258
  • Fax: 520-459-8619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP4673
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP 11835
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: