Provider Demographics
NPI:1093422685
Name:CARTER, KELLY R
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:CARTER
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 1:20751 WESTPORT AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-2841
Mailing Address - Country:US
Mailing Address - Phone:216-338-5894
Mailing Address - Fax:
Practice Address - Street 1:1541 E 191ST ST # K241
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-1330
Practice Address - Country:US
Practice Address - Phone:216-338-5894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide