Provider Demographics
NPI:1467134569
Name:HANSON, KELLY RAE (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RAE
Last Name:HANSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-5090
Mailing Address - Country:US
Mailing Address - Phone:928-432-5111
Mailing Address - Fax:
Practice Address - Street 1:500 HIGHWAY 89 NORTH
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86313-5001
Practice Address - Country:US
Practice Address - Phone:928-445-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ295242363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health