Provider Demographics
NPI:1629171053
Name:KELLY, MELISSA JANE
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JANE
Last Name:KELLY
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 1:7 NORTH DOAN AVE.
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-1426
Mailing Address - Country:US
Mailing Address - Phone:440-341-3512
Mailing Address - Fax:
Practice Address - Street 1:7 N DOAN AVE
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-1426
Practice Address - Country:US
Practice Address - Phone:440-341-3512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH433828030001Medicaid
OH103609531199Medicaid