Provider Demographics
NPI:1205611837
Name:KELLY, NICHOLAS MICHAEL
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MICHAEL
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 1:1118 BOULDER LN APT 302
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-8236
Mailing Address - Country:US
Mailing Address - Phone:234-542-9072
Mailing Address - Fax:
Practice Address - Street 1:2823 SOUREK RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44333-2707
Practice Address - Country:US
Practice Address - Phone:234-542-9072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program