Provider Demographics
NPI:1164416277
Name:KELLEY, MARY GAY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GAY
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12425 W BELL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-9006
Mailing Address - Country:US
Mailing Address - Phone:623-374-7774
Mailing Address - Fax:623-240-1110
Practice Address - Street 1:12425 W BELL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9006
Practice Address - Country:US
Practice Address - Phone:623-374-7774
Practice Address - Fax:623-240-1110
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP0029363LG0600X
AZAP2547363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ293709Medicaid
AZP00457902OtherMEDICARE RR
AZZ121009Medicare UPIN
AZP40021Medicare UPIN
AZZ144946Medicare PIN