Provider Demographics
NPI:1073034914
Name:RUSSELL, KEEGAN ASHLEY (FNP-C)
Entity Type:Individual
Prefix:
First Name:KEEGAN
Middle Name:ASHLEY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KEEGAN
Other - Middle Name:ASHLEY
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6423
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85246-6423
Mailing Address - Country:US
Mailing Address - Phone:480-314-6670
Mailing Address - Fax:480-257-1997
Practice Address - Street 1:8880 E DESERT COVE AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6746
Practice Address - Country:US
Practice Address - Phone:480-314-6670
Practice Address - Fax:480-314-6699
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ293629Medicaid