Provider Demographics
NPI:1013256338
Name:RAUCH, KELLY LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:RAUCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD STE 2200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2139
Mailing Address - Country:US
Mailing Address - Phone:602-633-3838
Mailing Address - Fax:602-633-3845
Practice Address - Street 1:7330 N 99TH AVE STE 325
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85307-3022
Practice Address - Country:US
Practice Address - Phone:623-882-1292
Practice Address - Fax:623-882-8184
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ213215OtherMEDICAID
AZ787564Medicaid