Provider Demographics
NPI:1013637925
Name:KELLY, CONN OSCAR
Entity type:Individual
Prefix:MR
First Name:CONN
Middle Name:OSCAR
Last Name:KELLY
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 1:2914 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-3052
Mailing Address - Country:US
Mailing Address - Phone:802-598-1282
Mailing Address - Fax:
Practice Address - Street 1:350 MIDWAY DRIVE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44242-0001
Practice Address - Country:US
Practice Address - Phone:802-598-1282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer