Provider Demographics
NPI:1336201219
Name:KELSO, THERESA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:
Last Name:KELSO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5616 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-8813
Mailing Address - Country:US
Mailing Address - Phone:480-396-3222
Mailing Address - Fax:480-396-2298
Practice Address - Street 1:5616 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8813
Practice Address - Country:US
Practice Address - Phone:480-396-3222
Practice Address - Fax:480-396-2298
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN095337363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167693Medicaid
AZ167693Medicaid