Provider Demographics
NPI:1952306318
Name:KIDD, KELLIE A (CNP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:A
Last Name:KIDD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-947-3700
Mailing Address - Fax:614-947-3771
Practice Address - Street 1:452 W 10TH AVENUE
Practice Address - Street 2:STE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210
Practice Address - Country:US
Practice Address - Phone:614-293-6638
Practice Address - Fax:614-293-5614
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07581NP363LF0000X
OHCOA07581NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2537964Medicaid
OH2537964Medicaid
Q28395Medicare UPIN