Provider Demographics
NPI:1477603801
Name:LIETTE, KELLY RENE
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENE
Last Name:LIETTE
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 1:303 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-1513
Mailing Address - Country:US
Mailing Address - Phone:937-548-1663
Mailing Address - Fax:937-548-7562
Practice Address - Street 1:303 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1513
Practice Address - Country:US
Practice Address - Phone:937-548-1663
Practice Address - Fax:937-548-7562
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2473532Medicaid