Provider Demographics
NPI:1033515655
Name:ROTHERMAL, KELLY (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ROTHERMAL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W PASEO REDONDO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-8274
Mailing Address - Country:US
Mailing Address - Phone:520-670-3909
Mailing Address - Fax:
Practice Address - Street 1:101 W IRVINGTON RD STE 10
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-3050
Practice Address - Country:US
Practice Address - Phone:520-670-3909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN160419163W00000X
AZTAP7403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse