Provider Demographics
NPI:1861851578
Name:CORDIAL, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CORDIAL
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:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:10650 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-9611
Practice Address - Country:US
Practice Address - Phone:606-408-6301
Practice Address - Fax:606-408-6350
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010151363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily