Basic Information
| Provider Information | |||||||||
| NPI: | 1366476004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIME | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OSGOOD | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19636 N 27TH AVE | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6237801999 | ||||||||
| FaxNumber: | 6235160950 | ||||||||
| Practice Location | |||||||||
| Address1: | 19636 N 27TH AVE | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6237801999 | ||||||||
| FaxNumber: | 6235160950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2701 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.