Provider Demographics
NPI:1134645492
Name:KELLEY, KRISTEN MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4726 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6929
Mailing Address - Country:US
Mailing Address - Phone:440-992-8552
Mailing Address - Fax:440-992-6631
Practice Address - Street 1:4726 MAIN AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6929
Practice Address - Country:US
Practice Address - Phone:440-992-8552
Practice Address - Fax:440-992-6631
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156981.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse