Provider Demographics
NPI:1265009096
Name:GREWELL, KELSEY ANGELINA
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANGELINA
Last Name:GREWELL
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 1:7033 PINECREST ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-2807
Mailing Address - Country:US
Mailing Address - Phone:330-491-7904
Mailing Address - Fax:
Practice Address - Street 1:4641 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2384
Practice Address - Country:US
Practice Address - Phone:330-433-6075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103288-TRNE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program