Provider Demographics
NPI:1053791202
Name:BARNETT, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BARNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BARNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:20 E CALLE DE FELICIDAD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-4914
Mailing Address - Country:US
Mailing Address - Phone:626-319-7573
Mailing Address - Fax:
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:ROOM 6336
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724
Practice Address - Country:US
Practice Address - Phone:520-626-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ55678207R00000X
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program