Provider Demographics
NPI:1790395531
Name:BANONIS, KELLY C (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:BANONIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:C
Other - Last Name:STUART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3322 N BRIGHTON
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-0997
Mailing Address - Country:US
Mailing Address - Phone:815-291-4460
Mailing Address - Fax:
Practice Address - Street 1:3322 N BRIGHTON
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-0997
Practice Address - Country:US
Practice Address - Phone:815-291-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ245540363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily