Provider Demographics
NPI:1184603342
Name:KENWORTHEY, MARY ELLEN (NP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:KENWORTHEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:MERVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2525 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4948
Mailing Address - Country:US
Mailing Address - Phone:602-344-1015
Mailing Address - Fax:
Practice Address - Street 1:2929 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-8034
Practice Address - Country:US
Practice Address - Phone:602-470-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-15
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN043733363LW0102X, 363LX0001X
AZAP0078363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ760406Medicaid
AZZ181809Medicare PIN
Z135053Medicare PIN
AZ760406Medicaid
AZS85932Medicare UPIN
S85932Medicare UPIN