Provider Demographics
NPI:1942973656
Name:FOLGHERAITER, KELLI BROOKE
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:BROOKE
Last Name:FOLGHERAITER
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 1:2078 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-5389
Mailing Address - Country:US
Mailing Address - Phone:928-776-6400
Mailing Address - Fax:855-633-3142
Practice Address - Street 1:2078 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-5389
Practice Address - Country:US
Practice Address - Phone:928-776-6400
Practice Address - Fax:855-633-3142
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ260085363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant