Basic Information
| Provider Information | |||||||||
| NPI: | 1497296362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1260 S CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856140503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204075600 | ||||||||
| FaxNumber: | 5204075990 | ||||||||
| Practice Location | |||||||||
| Address1: | 4475 S I 19 FRONTAGE RD STE 139 | ||||||||
| Address2: | |||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856145884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204075910 | ||||||||
| FaxNumber: | 5204075990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2017 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP9971 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.