Provider Demographics
NPI:1255456919
Name:MASON, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 VINE ST
Mailing Address - Street 2:
Mailing Address - City:SEAMAN
Mailing Address - State:OH
Mailing Address - Zip Code:45679-9702
Mailing Address - Country:US
Mailing Address - Phone:937-386-0507
Mailing Address - Fax:
Practice Address - Street 1:280 VINE ST
Practice Address - Street 2:
Practice Address - City:SEAMAN
Practice Address - State:OH
Practice Address - Zip Code:45679-9702
Practice Address - Country:US
Practice Address - Phone:937-386-0507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2663201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2663201Medicaid