Provider Demographics
NPI:1598754590
Name:EVANS, KELLY A (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:EVANS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MAHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2200 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2213 CHERRY ST STE ACC 200
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2603
Practice Address - Country:US
Practice Address - Phone:419-251-4283
Practice Address - Fax:419-251-0814
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAL089241363L00000X
MI4704251383363LA2100X
OHAPRN.CNP.022221363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA31415OtherBCBS
IA16496Medicare ID - Type Unspecified
IA31415OtherBCBS