Provider Demographics
NPI:1174803605
Name:WONG, KELLY MARIE (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:WONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6553 E BAYWOOD AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1754
Mailing Address - Country:US
Mailing Address - Phone:480-467-2273
Mailing Address - Fax:
Practice Address - Street 1:861 SW 78TH AVE
Practice Address - Street 2:STE 200B
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3273
Practice Address - Country:US
Practice Address - Phone:877-693-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner