Provider Demographics
NPI:1508565284
Name:BLUE SKY PSYCHIATRY LLC
Entity Type:Organization
Organization Name:BLUE SKY PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:NEMBU
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:817-658-2216
Mailing Address - Street 1:10553 W APPALOOSA TRL
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85194-7612
Mailing Address - Country:US
Mailing Address - Phone:817-658-2216
Mailing Address - Fax:
Practice Address - Street 1:2432 W PEORIA AVE STE 13421343
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4726
Practice Address - Country:US
Practice Address - Phone:817-658-2216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty