Provider Demographics
NPI:1124488317
Name:THOMPSON, KELLI SUE (FNP-C)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:SUE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:BEASLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:9977 N 90TH ST STE 350
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4434
Mailing Address - Country:US
Mailing Address - Phone:480-245-6126
Mailing Address - Fax:480-563-8009
Practice Address - Street 1:18555 N 79TH AVE STE D101
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6040
Practice Address - Country:US
Practice Address - Phone:480-563-8009
Practice Address - Fax:480-563-8009
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128449363LF0000X
AZAP11562363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX356798401Medicaid