Provider Demographics
NPI:1851639710
Name:MORDOCK, KELLY (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MORDOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 IRENA LN
Mailing Address - Street 2:
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087-2923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10085 DARROW RD
Practice Address - Street 2:
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-1409
Practice Address - Country:US
Practice Address - Phone:330-425-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-27
Last Update Date:2013-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14259-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily