1922000686 NPI number — KELLY RAE MCELROY FNP-C

Table of content: KELLY RAE MCELROY FNP-C (NPI 1922000686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922000686 NPI number — KELLY RAE MCELROY FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCELROY
Provider First Name:
KELLY
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922000686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18275 N 59TH AVE
Provider Second Line Business Mailing Address:
SUITE 142
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85308-1260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-765-2800
Provider Business Mailing Address Fax Number:
480-076-5279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5859 W TALAVI BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85306-1869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-298-7777
Provider Business Practice Location Address Fax Number:
623-930-6060
Provider Enumeration Date:
08/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  RN127856 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 967903 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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