Provider Demographics
NPI:1316178676
Name:KELLEHER, ANNETTE L (NP)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:L
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 E MOUNTAIN VIEW RD STE 220
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5172
Mailing Address - Country:US
Mailing Address - Phone:855-246-6287
Mailing Address - Fax:
Practice Address - Street 1:50 MAUDE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4325
Practice Address - Country:US
Practice Address - Phone:401-456-6616
Practice Address - Fax:401-456-6780
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP37519363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology