Provider Demographics
NPI:1033712393
Name:KELLY, AMBER JEANINE
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:JEANINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7612 STATE ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44093-9769
Mailing Address - Country:US
Mailing Address - Phone:330-787-7777
Mailing Address - Fax:
Practice Address - Street 1:7612 STATE ROUTE 7
Practice Address - Street 2:
Practice Address - City:WILLIAMSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44093-9769
Practice Address - Country:US
Practice Address - Phone:330-787-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0190711Medicaid