Provider Demographics
NPI:1255721734
Name:KLIMIS, KELLIE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:KLIMIS
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 1:2279 BEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:LOWELLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44436-9753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2360 SOUTHEAST BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-3418
Practice Address - Country:US
Practice Address - Phone:330-337-1134
Practice Address - Fax:330-337-1008
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16979-NP363LP2300X, 363L00000X
MI4704372859363LP2300X, 363L00000X
OHCOA.16979-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH16979-NPOtherOHIO LICENSE COA.