Provider Demographics
NPI:1497296362
Name:KELLY, STEPHANIE LYNN (NP-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 S CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-0503
Mailing Address - Country:US
Mailing Address - Phone:520-407-5600
Mailing Address - Fax:520-407-5990
Practice Address - Street 1:4475 S I 19 FRONTAGE RD STE 139
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-5884
Practice Address - Country:US
Practice Address - Phone:520-407-5910
Practice Address - Fax:520-407-5990
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP9971363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily