Provider Demographics
NPI:1629541198
Name:SHEETS, KELLY RAE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:SHEETS
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:PO BOX 1222
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-6022
Mailing Address - Country:US
Mailing Address - Phone:740-258-0649
Mailing Address - Fax:
Practice Address - Street 1:343 1/2 W FAIR AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-1864
Practice Address - Country:US
Practice Address - Phone:740-258-0649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRT511298374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2747675Medicaid