Provider Demographics
NPI:1184822348
Name:FAVATA, KELLI RAYNELL (MD)
Entity type:Individual
Prefix:DR
First Name:KELLI
Middle Name:RAYNELL
Last Name:FAVATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 NORTHDALE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1893
Mailing Address - Country:US
Mailing Address - Phone:800-911-6117
Mailing Address - Fax:
Practice Address - Street 1:3530 S VAL VISTA DR STE B210
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7318
Practice Address - Country:US
Practice Address - Phone:800-991-6117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30177207R00000X
AZ45344207R00000X, 246XC2903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XC2903XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularVascular Specialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ654974Medicaid