Provider Demographics
NPI:1689101362
Name:KELLY, ALLYSEN (NP)
Entity Type:Individual
Prefix:
First Name:ALLYSEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2077 E WILLIS RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-2087
Mailing Address - Country:US
Mailing Address - Phone:928-587-7097
Mailing Address - Fax:
Practice Address - Street 1:2077 E WILLIS RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-2087
Practice Address - Country:US
Practice Address - Phone:928-587-1147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10040363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily