Provider Demographics
NPI:1326821117
Name:KISS-JAGODA, KELLY KATHERINE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KATHERINE
Last Name:KISS-JAGODA
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 1:16915 OLD STATE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44062-9141
Mailing Address - Country:US
Mailing Address - Phone:440-532-9143
Mailing Address - Fax:
Practice Address - Street 1:16915 OLD STATE RD
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:OH
Practice Address - Zip Code:44062-9141
Practice Address - Country:US
Practice Address - Phone:440-532-9143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker