Provider Demographics
NPI:1265915714
Name:KELLEY, JACQUELINE MARY (RN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARY
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 SPRING GROVE DR
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1341
Mailing Address - Country:US
Mailing Address - Phone:330-701-6087
Mailing Address - Fax:330-543-3782
Practice Address - Street 1:591 SPRING GROVE DR
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-1341
Practice Address - Country:US
Practice Address - Phone:330-701-6087
Practice Address - Fax:330-543-3782
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.430788163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool