Provider Demographics
NPI:1528416609
Name:MCCLOSKEY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCCLOSKEY
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 1:11225 ALEXA DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-8557
Mailing Address - Country:US
Mailing Address - Phone:440-289-9231
Mailing Address - Fax:
Practice Address - Street 1:11225 ALEXA DR
Practice Address - Street 2:
Practice Address - City:CONCORD TWP
Practice Address - State:OH
Practice Address - Zip Code:44077-8557
Practice Address - Country:US
Practice Address - Phone:440-289-9231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-30
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2755362Medicaid