Provider Demographics
NPI:1912958232
Name:KELLY, TRACI L (RN, FNP)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:3707 N 7TH ST
Mailing Address - Street 2:#305
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5059
Mailing Address - Country:US
Mailing Address - Phone:602-264-9100
Mailing Address - Fax:602-264-9101
Practice Address - Street 1:349 E CORONADO RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1525
Practice Address - Country:US
Practice Address - Phone:602-266-5678
Practice Address - Fax:602-264-5646
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN0604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ120390OtherGROUP MEDICARE NUMBER
AZ317047OtherGROUP MEDICAID NUMBER
AZS54104Medicare UPIN