Provider Demographics
NPI:1427646025
Name:SAMPLE, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12065 NICKI LN
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-8941
Mailing Address - Country:US
Mailing Address - Phone:440-226-0867
Mailing Address - Fax:
Practice Address - Street 1:12065 NICKI LN
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-8941
Practice Address - Country:US
Practice Address - Phone:440-226-0867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker