Provider Demographics
NPI:1073849360
Name:KELLY, LUANNE TAKACS (NP)
Entity Type:Individual
Prefix:DR
First Name:LUANNE
Middle Name:TAKACS
Last Name:KELLY
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 1:14609 N 60TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3805
Mailing Address - Country:US
Mailing Address - Phone:520-340-8686
Mailing Address - Fax:623-738-4025
Practice Address - Street 1:2400 W DUNLAP AVE STE 125
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2885
Practice Address - Country:US
Practice Address - Phone:520-340-8686
Practice Address - Fax:623-738-0425
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3594363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ048119OtherANCC
AZAP3594OtherARIZONA BOARD OF NURSING
AZZ25025OtherMEDICARE
AZ1073849360Medicaid
AZ618876Medicaid
PAUP80001BOtherNP LICENSE