Provider Demographics
NPI:1912653536
Name:BLACK, KELLY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 S STAPLEY DR STE 120
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6676
Mailing Address - Country:US
Mailing Address - Phone:951-623-7194
Mailing Address - Fax:
Practice Address - Street 1:1910 S STAPLEY DR STE 120
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6676
Practice Address - Country:US
Practice Address - Phone:602-341-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56220163WP0808X
AZ305924363LP0808X
CA95024873363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ305924OtherARIZONA BOARD OF NURSING CERTIFIED NURSE PRACTITIONER LICENSE PMHNP-BC