Provider Demographics
NPI:1326066838
Name:MAURER, KELLY ANNE (NP)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:ANNE
Last Name:MAURER
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:PO BOX 61773
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-1773
Mailing Address - Country:US
Mailing Address - Phone:602-266-2200
Mailing Address - Fax:602-240-6177
Practice Address - Street 1:2632 N 20TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-1339
Practice Address - Country:US
Practice Address - Phone:602-266-2200
Practice Address - Fax:602-240-6177
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN064636163W00000X
AZ2433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ173959Medicaid
AZWCSKQOtherSUN HEALTH GROUP #
AZP00344216OtherRAILROAD MEDICARE
AZRN064636OtherRN LICENSE NUMBER
AZ2433OtherAZ NP LICENSE
AZWCSKQOtherSUN HEALTH GROUP #
AZZ111391Medicare PIN