Provider Demographics
NPI:1578225637
Name:WALLEN, KELLY JO
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:WALLEN
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 1:287 E. LEFFEL LANE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505
Mailing Address - Country:US
Mailing Address - Phone:937-342-3041
Mailing Address - Fax:937-342-4497
Practice Address - Street 1:287 E. LEFFEL LANE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505
Practice Address - Country:US
Practice Address - Phone:937-342-3041
Practice Address - Fax:937-342-4497
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.155614.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse