Provider Demographics
NPI:1255713400
Name:KIRK, KELLY ANN (AGACNP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:KIRK
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1785
Mailing Address - Country:US
Mailing Address - Phone:513-475-8922
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-475-8282
Practice Address - Fax:513-458-1986
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.359897363LA2100X
OHCOA17712-NP363LA2100X
OHCNP17712363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0138175Medicaid
H366010Medicare UPIN
OH0138175Medicaid