Provider Demographics
NPI:1003462615
Name:PARKS, KELLY MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:PARKS
Suffix:
Gender:
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8730 WATERVILLE SWANTON RD
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-9726
Mailing Address - Country:US
Mailing Address - Phone:419-878-1049
Mailing Address - Fax:419-878-1053
Practice Address - Street 1:8730 WATERVILLE SWANTON RD
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-9726
Practice Address - Country:US
Practice Address - Phone:419-878-1049
Practice Address - Fax:419-878-1053
Is Sole Proprietor?:No
Enumeration Date:2019-08-11
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily