MEDICARE: NICOLE ANGELA KELLY-GORDON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW-15933	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851752224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE ANGELA KELLY-GORDON

Provider Business Mailing Address
First Line	:	5240 E IDLEWOOD LN
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-8719
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2925 W ROSE GARDEN LN STE 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-3135
Country	:	US
Telephone Number	:	623-265-7215
Fax Number	:	833-465-1462

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2016
Last Update Date	:	10/14/2022

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