Kelly Black, PMHNP-BC

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

95024873 Issued in CA

Practice address

1910 S Stapley Dr Ste 120
Mesa, AZ 85204-6676

Phone

(602) 341-3303

NPI assigned

Feb 22, 2022

Last updated

Feb 6, 2025By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Ahp Psych NP PC

  • Psychiatric/Mental Health Nurse Practitioner
  • Mesa, AZ
  • NPI 1649094012
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1645488000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1738800000000",
    "number": "1912653536",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1910 S STAPLEY DR STE 120",
            "city": "MESA",
            "state": "AZ",
            "postal_code": "852046676",
            "telephone_number": "951-623-7194"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1910 S STAPLEY DR STE 120",
            "city": "MESA",
            "state": "AZ",
            "postal_code": "852046676",
            "telephone_number": "602-341-3303"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "32205 Snyder Ln",
            "address_purpose": "LOCATION",
            "city": "Homeland",
            "state": "CA",
            "postal_code": "925489600",
            "country_code": "US",
            "telephone_number": "951-623-7194",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BLACK",
        "first_name": "KELLY",
        "credential": "PMHNP-BC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-02-22",
        "last_updated": "2025-02-06",
        "certification_date": "2025-02-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "AZ",
            "license": "305924",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "CA",
            "license": "95024873",
            "primary": true
        },
        {
            "code": "163WP0808X",
            "taxonomy_group": "",
            "desc": "Registered Nurse, Psychiatric/Mental Health",
            "state": "CA",
            "license": "56220",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ARIZONA BOARD OF NURSING CERTIFIED NURSE PRACTITIONER LICENSE PMHNP-BC",
            "identifier": "305924",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Karen Bjorn, PA
• BKJM LLC
• Andrew Black, DO
• Erika Black, MSW, LMSW
• Jessica Black
• Nicole Black, COTA
• Timothy E Black, MD
• Blackbird Senior Living, Inc. (The Citadel Assisted Living Facility)
• Patrick Wayne Blackburn, MD
• Jared Blacker, DDS

• Psychiatric/Mental Health Nurse Practitioner in Mesa, AZ
• Providers in Mesa, AZ by specialty
• Psychiatric/Mental Health Nurse Practitioner in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.