=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740424647
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLI ANDERSON FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2009
-----------------------------------------------------
Last Update Date | 05/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4840 E INDIAN SCHOOL RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85018-5500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-954-3919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12112 W DESERT MIRAGE DR
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85383-8201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-692-0575
-----------------------------------------------------
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 | AP3309
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------