Provider Demographics
NPI:1336307495
Name:KELLER, COURTNEY ANN (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:ANN
Last Name:KELLER
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:ANN
Other - Last Name:KONDOS/MERCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-CNS
Mailing Address - Street 1:9165 W THUNDERBIRD RD SUITE 201
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4847
Mailing Address - Country:US
Mailing Address - Phone:623-876-8420
Mailing Address - Fax:623-285-2626
Practice Address - Street 1:9165 W THUNDERBIRD RD SUITE 201
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4847
Practice Address - Country:US
Practice Address - Phone:623-876-8420
Practice Address - Fax:623-285-2626
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7558363LP0808X
ND46364SP0807X, 364SP0809X
AZRN173592363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & AdolescentGroup - Multi-Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND054517Medicaid
AZ979757Medicaid
NDPENDINGOtherTRICARE
NDPENDINGOtherBCBS ND