Provider Demographics
NPI:1932652682
Name:CHERRY, KIELAN
Entity Type:Individual
Prefix:MS
First Name:KIELAN
Middle Name:
Last Name:CHERRY
Suffix:
Gender:M
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 4009
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-0009
Mailing Address - Country:US
Mailing Address - Phone:330-245-7456
Mailing Address - Fax:
Practice Address - Street 1:1255 VALE DR
Practice Address - Street 2:APT D
Practice Address - City:COPLEY
Practice Address - State:OH
Practice Address - Zip Code:44321-2183
Practice Address - Country:US
Practice Address - Phone:330-245-7456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSK616189172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver