Provider Demographics
NPI:1326230475
Name:BRADEN, KELLY LYNN (NP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:BRADEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:333 N SUMMIT ST 7TH FL
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604
Mailing Address - Country:US
Mailing Address - Phone:419-690-7596
Mailing Address - Fax:419-697-6707
Practice Address - Street 1:2751 BAY PARK DRIVE #300
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616
Practice Address - Country:US
Practice Address - Phone:419-690-7596
Practice Address - Fax:419-697-6707
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-09492363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
48351OtherHEALTH PLAN OF MICHIGAN
OH000000557727OtherANTHEM
48351OtherHEALTH PLAN OF MICHIGAN
OHKBNP26412Medicare PIN
48351OtherHEALTH PLAN OF MICHIGAN
MIMI1174019Medicare PIN