Provider Demographics
NPI:1245398353
Name:WHALEY, KELLY RADER (DPM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RADER
Last Name:WHALEY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RADER
Other - Last Name:SWIGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 182
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-0182
Mailing Address - Country:US
Mailing Address - Phone:216-229-0292
Mailing Address - Fax:440-975-1963
Practice Address - Street 1:144 LARIMAR DR
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-5212
Practice Address - Country:US
Practice Address - Phone:216-229-0292
Practice Address - Fax:440-975-1963
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3068213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2138467Medicaid
OH2138467Medicaid
SW0878181Medicare ID - Type Unspecified