Individual
KELLY BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PMHNP-BC
Contact information
Practice address
1910 S STAPLEY DR STE 120, MESA, AZ 85204-6676
(602) 341-3303
Mailing address
1910 S STAPLEY DR STE 120, MESA, AZ 85204-6676
(951) 623-7194
Taxonomy
Speciality
Code
Description
License number
State
163WP0808X
Psychiatric/Mental Health Registered Nurse
56220
CA
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
305924
AZ
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
95024873
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
305924
ARIZONA BOARD OF NURSING CERTIFIED NURSE PRACTITIONER LICENSE PMHNP-BC
AZ
Enumeration date
02/22/2022
Last updated
02/06/2025
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