Provider Demographics
NPI:1558652495
Name:GIFFORD, KELLY K (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:GIFFORD
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 1:637 JOELL LN
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-1964
Mailing Address - Country:US
Mailing Address - Phone:740-464-5263
Mailing Address - Fax:
Practice Address - Street 1:303 GERVAIS RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN FURNACE
Practice Address - State:OH
Practice Address - Zip Code:45629-8742
Practice Address - Country:US
Practice Address - Phone:740-259-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.N. 142099 M IV164W00000X
OH392196163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH392196OtherOHIO BOARD OF NURSING