Provider Demographics
NPI:1730316886
Name:KENNELLY, COLAN ASHLEY (MD)
Entity Type:Individual
Prefix:
First Name:COLAN
Middle Name:ASHLEY
Last Name:KENNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 12TH ST
Mailing Address - Street 2:#605
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:#605
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-239-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR71518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine