Provider Demographics
NPI:1023027661
Name:KELLEY, JUDITH AMANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:AMANDA
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2886 W NORIA ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-0940
Mailing Address - Country:US
Mailing Address - Phone:928-607-3864
Mailing Address - Fax:
Practice Address - Street 1:1020 N SAN FRANCISCO ST
Practice Address - Street 2:STE 100
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3281
Practice Address - Country:US
Practice Address - Phone:928-214-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30354207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ708274Medicaid
AZZ71655Medicare ID - Type Unspecified
AZZ71655Medicare PIN
AZ708274Medicaid