Provider Demographics
NPI:1336118678
Name:KELLEY, SUZANNE (NP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:KELLEY
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 1:222 W THOMAS RD STE 114
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4420
Mailing Address - Country:US
Mailing Address - Phone:602-406-6304
Mailing Address - Fax:602-406-6302
Practice Address - Street 1:222 W THOMAS RD STE 114
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4420
Practice Address - Country:US
Practice Address - Phone:602-406-6304
Practice Address - Fax:602-406-6302
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN063733363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRN063733OtherNURSING LICENSE