Provider Demographics
NPI:1740895994
Name:CLARKE, KELLI DEE (CRNA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:DEE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:DEE
Other - Last Name:GLEASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:940 S 131ST ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-7602
Mailing Address - Country:US
Mailing Address - Phone:480-229-1535
Mailing Address - Fax:
Practice Address - Street 1:8339 E VISTA DR
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-7321
Practice Address - Country:US
Practice Address - Phone:480-229-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ247493367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered