Provider Demographics
NPI:1568847895
Name:RODGERS, KELLY NICOLE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:RODGERS
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 1:3616 WAYNESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:OH
Mailing Address - Zip Code:45370-9727
Mailing Address - Country:US
Mailing Address - Phone:513-236-9396
Mailing Address - Fax:
Practice Address - Street 1:3616 WAYNESVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:OH
Practice Address - Zip Code:45370-9727
Practice Address - Country:US
Practice Address - Phone:513-236-9396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.159610-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse