Provider Demographics
NPI:1427137157
Name:SCOGGINS, KELLY L (FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:SCOGGINS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 W THUNDERBIRD RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4706
Mailing Address - Country:US
Mailing Address - Phone:602-865-4065
Mailing Address - Fax:
Practice Address - Street 1:5310 W THUNDERBIRD RD
Practice Address - Street 2:SUITE 110
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4706
Practice Address - Country:US
Practice Address - Phone:602-865-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN124662163WP0200X
AZ124662208600000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ826737Medicaid
AZ826737Medicaid