Provider Demographics
NPI:1346891462
Name:MAERTZ, KELLIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:MAERTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:NIEHAUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5400 DOVETREE BLVD APT 5
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-2185
Mailing Address - Country:US
Mailing Address - Phone:216-233-8018
Mailing Address - Fax:
Practice Address - Street 1:3533 SOUTHERN BLVD STE 2100
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1267
Practice Address - Country:US
Practice Address - Phone:216-233-8018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant