Provider Demographics
NPI:1376792523
Name:OSBORNE, KELLY YVONNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:YVONNE
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:YVONNE
Other - Last Name:SWEETING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:269 PORTLAND WAY S
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833-2312
Practice Address - Country:US
Practice Address - Phone:419-468-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002812363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0106642Medicaid