Provider Demographics
NPI:1043234610
Name:CZARNECKI, KELLY MICHELE (PAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELE
Last Name:CZARNECKI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MICHELE
Other - Last Name:FELKINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1490 N TURQUOISE DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-774-5074
Mailing Address - Fax:928-774-0884
Practice Address - Street 1:1490 N TURQUOISE DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-774-5074
Practice Address - Fax:928-774-0884
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ56246Medicaid
P78270Medicare UPIN
AZ56246Medicaid