Provider Demographics
NPI:1184010639
Name:KELLY, CHRISTINA DEBAUN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:DEBAUN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 N VALLEY OAK DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7720
Mailing Address - Country:US
Mailing Address - Phone:972-310-9712
Mailing Address - Fax:
Practice Address - Street 1:2601 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008
Practice Address - Country:US
Practice Address - Phone:602-344-5956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-11
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01080214A207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine