Provider Demographics
NPI:1265267645
Name:KELLY, SUE ANNE MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:SUE ANNE
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 COUNTY ROAD 5 N
Mailing Address - Street 2:
Mailing Address - City:ZANESFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:43360-9747
Mailing Address - Country:US
Mailing Address - Phone:937-407-3330
Mailing Address - Fax:
Practice Address - Street 1:4879 US HIGHWAY 68 S
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:OH
Practice Address - Zip Code:43357-9525
Practice Address - Country:US
Practice Address - Phone:937-599-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRNCNP-0036950363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily