Provider Demographics
NPI:1326682790
Name:HUFFAKER, KELLY L (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:HUFFAKER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2647 E BUTTE CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-8432
Mailing Address - Country:US
Mailing Address - Phone:480-239-2106
Mailing Address - Fax:
Practice Address - Street 1:4001 E BASELINE RD STE 204
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2743
Practice Address - Country:US
Practice Address - Phone:480-565-6440
Practice Address - Fax:480-454-1085
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRNP234095363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health