Provider Demographics
NPI:1144213000
Name:CARPENTER, KELLY (RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 53568
Mailing Address - Street 2:SUN HEALTH CLINICS BUSINESS OFFICE
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072
Mailing Address - Country:US
Mailing Address - Phone:623-544-5075
Mailing Address - Fax:623-544-5093
Practice Address - Street 1:10401 W THUNDERBIRD BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3004
Practice Address - Country:US
Practice Address - Phone:623-876-5455
Practice Address - Fax:623-876-6687
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ863763Medicaid
AZ863763Medicaid