Provider Demographics
NPI:1366039935
Name:SLAVIK-BOSWORTH, KELLY J (CNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:SLAVIK-BOSWORTH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 KOLBE RD
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1611
Mailing Address - Country:US
Mailing Address - Phone:440-960-4416
Mailing Address - Fax:440-960-4417
Practice Address - Street 1:3700 KOLBE RD
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1611
Practice Address - Country:US
Practice Address - Phone:440-960-4416
Practice Address - Fax:440-960-4417
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0028216363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0427883Medicaid