Provider Demographics
NPI:1760739916
Name:SHELLEY, KAYLA MARIE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:SHELLEY
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 1:2163 E BASELINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1541
Mailing Address - Country:US
Mailing Address - Phone:480-646-8123
Mailing Address - Fax:480-646-8125
Practice Address - Street 1:2163 E BASELINE RD STE 101
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1541
Practice Address - Country:US
Practice Address - Phone:480-646-8123
Practice Address - Fax:480-646-8125
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ115413Medicaid