Provider Demographics
NPI:1750160172
Name:FORKASDI, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FORKASDI
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 1:34250 N 60TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85266-5201
Mailing Address - Country:US
Mailing Address - Phone:602-448-1979
Mailing Address - Fax:
Practice Address - Street 1:34250 N 60TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85266-5201
Practice Address - Country:US
Practice Address - Phone:480-596-9622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 171400000X
AZ174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator