Provider Demographics
NPI:1295041507
Name:JIMENEZ, KELLY M
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:M
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:DUNAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29774 N 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-3173
Mailing Address - Country:US
Mailing Address - Phone:219-808-0293
Mailing Address - Fax:
Practice Address - Street 1:5324 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-2144
Practice Address - Country:US
Practice Address - Phone:602-732-3384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020635A183500000X
AZS017785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist