Provider Demographics
NPI:1962067363
Name:FLOM RACOMA, KEHART LYNN
Entity type:Individual
Prefix:
First Name:KEHART
Middle Name:LYNN
Last Name:FLOM RACOMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 E MERCER LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3437
Mailing Address - Country:US
Mailing Address - Phone:602-300-0975
Mailing Address - Fax:
Practice Address - Street 1:4527 N 16TH ST STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5353
Practice Address - Country:US
Practice Address - Phone:602-845-8000
Practice Address - Fax:602-845-8001
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ230888207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty