Provider Demographics
NPI:1578249686
Name:STAKE, KELLY JOY (MSN, APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JOY
Last Name:STAKE
Suffix:
Gender:F
Credentials:MSN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 PEARL RD
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-2007
Mailing Address - Country:US
Mailing Address - Phone:419-651-4111
Mailing Address - Fax:
Practice Address - Street 1:5550 VENTURE DR
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44130-9315
Practice Address - Country:US
Practice Address - Phone:216-201-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.393241363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health