Provider Demographics
NPI:1215550348
Name:FAILLACE, KELSIE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:NICOLE
Last Name:FAILLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSIE
Other - Middle Name:NICOLE
Other - Last Name:DIRKSING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML 2010
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4415
Mailing Address - Fax:513-636-7805
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-708-8146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-23
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH50.006434RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program