Provider Demographics
NPI:1992194211
Name:BLINN, KELLI SHEARRON (CLC)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:SHEARRON
Last Name:BLINN
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 DEMING AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-2444
Mailing Address - Country:US
Mailing Address - Phone:614-395-3792
Mailing Address - Fax:
Practice Address - Street 1:2675 DEMING AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-2444
Practice Address - Country:US
Practice Address - Phone:614-395-3792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH202793174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH202793OtherALPP