Provider Demographics
NPI:1164435582
Name:KELLY, PATRICIA A (NMD, FNP-BC, GNPC-BC)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:NMD, FNP-BC, GNPC-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 CORPORATE EXCHANGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-7689
Mailing Address - Country:US
Mailing Address - Phone:888-528-5595
Mailing Address - Fax:562-528-5595
Practice Address - Street 1:200 OCEANGATE STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4317
Practice Address - Country:US
Practice Address - Phone:888-562-5442
Practice Address - Fax:562-528-5595
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP04543363L00000X
IN71000324A363LF0000X
OHAPRN.CNP.04543363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000577056OtherANTHEM
OH421534506126OtherCARESOURCE
OH2271741Medicaid
OH2271741Medicaid
OH1164435582OtherMMOH