Provider Demographics
NPI:1619405313
Name:ANDRIST, KELSEY YVONNE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:YVONNE
Last Name:ANDRIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 S RIORDAN RANCH ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-6372
Mailing Address - Country:US
Mailing Address - Phone:866-991-0900
Mailing Address - Fax:
Practice Address - Street 1:1510 S RIORDAN RANCH ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-6372
Practice Address - Country:US
Practice Address - Phone:928-214-7303
Practice Address - Fax:928-214-0696
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13028225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ304228Medicaid