Provider Demographics
NPI:1518561083
Name:PICKENS, KELSEA
Entity Type:Individual
Prefix:
First Name:KELSEA
Middle Name:
Last Name:PICKENS
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 1:502 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2522
Mailing Address - Country:US
Mailing Address - Phone:567-376-9565
Mailing Address - Fax:
Practice Address - Street 1:26737 NAWASH DR
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5464
Practice Address - Country:US
Practice Address - Phone:419-345-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH347C00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No347C00000XTransportation ServicesPrivate Vehicle