Provider Demographics
NPI:1639343742
Name:KELCH, KIMBERLY K (ACNP-BC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:K
Last Name:KELCH
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 N DYSART RD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-1213
Mailing Address - Country:US
Mailing Address - Phone:602-439-6784
Mailing Address - Fax:602-371-4960
Practice Address - Street 1:6818 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5025
Practice Address - Country:US
Practice Address - Phone:623-566-3550
Practice Address - Fax:623-566-3573
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN13358363L00000X
FLARNP9319197363LA2100X
AZAP4061363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
1031502218Medicare PIN
3341826Medicare PIN