Provider Demographics
NPI:1104867308
Name:WARD, KELLI M (DO)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:WARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-213-6100
Mailing Address - Fax:928-774-6687
Practice Address - Street 1:2090 SMOKETREE AVE N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5806
Practice Address - Country:US
Practice Address - Phone:928-854-1800
Practice Address - Fax:928-854-1847
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-05-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ3425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ470724Medicaid
AZ470724Medicaid