Provider Demographics
NPI:1093283483
Name:MARSHALL, KELLY L (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:7700 E FLORENTINE RD STE 101
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2245
Practice Address - Country:US
Practice Address - Phone:928-442-8710
Practice Address - Fax:928-442-8742
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ219517363LF0000X
AZF101814346363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ466479Medicaid