Provider Demographics
NPI:1629859590
Name:KELLEY, KATRINA
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:KELLEY
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 1:542 THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43103-2507
Mailing Address - Country:US
Mailing Address - Phone:937-999-9937
Mailing Address - Fax:
Practice Address - Street 1:542 THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:ASHVILLE
Practice Address - State:OH
Practice Address - Zip Code:43103-2507
Practice Address - Country:US
Practice Address - Phone:937-999-9937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker