Provider Demographics
NPI:1275046823
Name:WASMUND, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:WASMUND
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 1:11343 HONEY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:THORNVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43076-9205
Mailing Address - Country:US
Mailing Address - Phone:614-561-6847
Mailing Address - Fax:
Practice Address - Street 1:17606 COSHOCTON RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9218
Practice Address - Country:US
Practice Address - Phone:740-397-7568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator