Provider Demographics
NPI:1730320623
Name:SOUTHWELL, KAY LYNN (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:KAY
Middle Name:LYNN
Last Name:SOUTHWELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:LYNN
Other - Last Name:SOUTHERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6242 E ARBOR AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1309
Mailing Address - Country:US
Mailing Address - Phone:480-610-8183
Mailing Address - Fax:480-610-8566
Practice Address - Street 1:6242 E ARBOR AVE SUITE 111
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2809
Practice Address - Country:US
Practice Address - Phone:480-610-8183
Practice Address - Fax:480-610-8566
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704216251363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B56065OtherMEDICARE PART B
AZ0B56065OtherMEDICARE PART B