Provider Demographics
NPI:1467051821
Name:MUCHMORE, KELSEY NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:NICOLE
Last Name:MUCHMORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:NICOLE
Other - Last Name:WEISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 636256
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-246-1964
Mailing Address - Fax:513-245-3672
Practice Address - Street 1:3200 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3019
Practice Address - Country:US
Practice Address - Phone:513-475-7505
Practice Address - Fax:513-475-7355
Is Sole Proprietor?:No
Enumeration Date:2020-10-18
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006594RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0459280Medicaid