Provider Demographics
NPI:1790430999
Name:GOTHARD, KELSI
Entity Type:Individual
Prefix:
First Name:KELSI
Middle Name:
Last Name:GOTHARD
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 1:121 COUNTY ROAD 49
Mailing Address - Street 2:
Mailing Address - City:PEDRO
Mailing Address - State:OH
Mailing Address - Zip Code:45659-8609
Mailing Address - Country:US
Mailing Address - Phone:740-646-3831
Mailing Address - Fax:
Practice Address - Street 1:121 COUNTY ROAD 49
Practice Address - Street 2:
Practice Address - City:PEDRO
Practice Address - State:OH
Practice Address - Zip Code:45659-8609
Practice Address - Country:US
Practice Address - Phone:740-646-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant