Provider Demographics
NPI:1710190822
Name:MERCER, KELLY
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:
Last Name:MERCER
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 1:117 MENDOTA ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2420
Mailing Address - Country:US
Mailing Address - Phone:419-589-4921
Mailing Address - Fax:
Practice Address - Street 1:117 MENDOTA ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2420
Practice Address - Country:US
Practice Address - Phone:419-589-4921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
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
OH2721755Medicaid