Provider Demographics
NPI:1295340701
Name:MARKS, KELLY DIANE
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:DIANE
Last Name:MARKS
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 1:3145 STANDISH AVE SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44706-3250
Mailing Address - Country:US
Mailing Address - Phone:330-224-2333
Mailing Address - Fax:
Practice Address - Street 1:3145 STANDISH AVE SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44706-3250
Practice Address - Country:US
Practice Address - Phone:330-224-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7611065Medicaid