Provider Demographics
NPI:1508315391
Name:KELLY, KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:YEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:9000 N MAIN ST STE 232
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415
Practice Address - Country:US
Practice Address - Phone:937-277-8988
Practice Address - Fax:937-277-9035
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004784RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0186637Medicaid
OH0186637Medicaid