Provider Demographics
NPI:1083499057
Name:KISTLER, KELLY RENE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENE
Last Name:KISTLER
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 1:5117 CAMP RUN RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45121-8291
Mailing Address - Country:US
Mailing Address - Phone:937-822-1808
Mailing Address - Fax:
Practice Address - Street 1:5117 CAMP RUN RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-8291
Practice Address - Country:US
Practice Address - Phone:937-822-1808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker