Provider Demographics
NPI:1730320623
Name:SOUTHWELL, KAY LYNN (PMHNP-BC,NPC)
Entity type:Individual
Prefix:MRS
First Name:KAY
Middle Name:LYNN
Last Name:SOUTHWELL
Suffix:
Gender:F
Credentials:PMHNP-BC,NPC
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:LYNN
Other - Last Name:SOUTHERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7156 E OLLA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-9802
Mailing Address - Country:US
Mailing Address - Phone:810-919-6247
Mailing Address - Fax:
Practice Address - Street 1:1910 S STAPLEY DR STE 217
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6679
Practice Address - Country:US
Practice Address - Phone:602-888-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704216251363LP2300X
AZAP8742363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0B56065OtherMEDICARE PART B
MI0B56065OtherMEDICARE PART B