Basic Information
| Provider Information | |||||||||
| NPI: | 1619948064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELM | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCDANIEL | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | G | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20280 N 59TH AVE | ||||||||
| Address2: | STE 115-617 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853086850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027958700 | ||||||||
| FaxNumber: | 6027958701 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 S DOBSON RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027958700 | ||||||||
| FaxNumber: | 6027958701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 12/16/2015 | ||||||||
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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 | 363AM0700X | 2515 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 623307 | 05 | AZ | MEDICAID |