=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639840382
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY MARIE JEFFRIES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2021
-----------------------------------------------------
Last Update Date | 02/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 W AERO DR
-----------------------------------------------------
City | PAYSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85541-5405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-466-4242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 896
-----------------------------------------------------
City | WARNER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74469-0896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-709-6011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 263498
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------