Provider Demographics
NPI:1790087344
Name:ELLCESSOR, KELLY S (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:ELLCESSOR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 BAKER CT
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-9069
Mailing Address - Country:US
Mailing Address - Phone:419-310-0176
Mailing Address - Fax:
Practice Address - Street 1:512 BAKER CT
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-9069
Practice Address - Country:US
Practice Address - Phone:419-310-0176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-01
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN111860164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse