Provider Demographics
NPI:1265627889
Name:KANZEG, KELLY J
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:KANZEG
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 1:319 TOWNSHIP ROAD 581
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:OH
Mailing Address - Zip Code:44880-9767
Mailing Address - Country:US
Mailing Address - Phone:330-421-6844
Mailing Address - Fax:
Practice Address - Street 1:319 TOWNSHIP ROAD 581
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:OH
Practice Address - Zip Code:44880-9767
Practice Address - Country:US
Practice Address - Phone:330-421-6844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH098645164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse