Basic Information
| Provider Information | |||||||||
| NPI: | 1356422471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80217 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850600217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023852115 | ||||||||
| FaxNumber: | 4804183323 | ||||||||
| Practice Location | |||||||||
| Address1: | 3033 N 44TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850187227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026313161 | ||||||||
| FaxNumber: | 6026313162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 3487 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 3487 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 162787 | 05 | AZ | MEDICAID |