=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235174731
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA DEANN PELLICORE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2006
-----------------------------------------------------
Last Update Date | 04/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 E WESTERN AVE STE 104
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-230-7373
-----------------------------------------------------
Fax | 602-230-3086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3101 N CENTRAL AVE STE 550
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-230-7373
-----------------------------------------------------
Fax | 602-682-7455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01057388A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 48328
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------