Provider Demographics
NPI:1609236926
Name:PARKER, KELLY K
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:PARKER
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 1:100 7TH AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-7804
Mailing Address - Country:US
Mailing Address - Phone:440-286-8841
Mailing Address - Fax:
Practice Address - Street 1:100 7TH AVE
Practice Address - Street 2:111
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024
Practice Address - Country:US
Practice Address - Phone:440-286-8841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH380065163W00000X
OH18732363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse