Provider Demographics
NPI:1447445564
Name:LORENTSEN, KELLI JO (MD)
Entity type:Individual
Prefix:DR
First Name:KELLI
Middle Name:JO
Last Name:LORENTSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 E ROOSEVELT ST
Mailing Address - Street 2:MARICOPA MEDICAL CENTER, PEDS ED
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4973
Mailing Address - Country:US
Mailing Address - Phone:602-344-5404
Mailing Address - Fax:
Practice Address - Street 1:2601 E ROOSEVELT ST
Practice Address - Street 2:MARICOPA MEDICAL CENTER, PEDS ED
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4973
Practice Address - Country:US
Practice Address - Phone:602-344-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21820208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ191320Medicaid
F92220Medicare UPIN