Provider Demographics
NPI:1649945965
Name:MAYBERRY, KELLY JEAN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:MAYBERRY
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 1:68200 JENNY LYNN DR
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43718-9444
Mailing Address - Country:US
Mailing Address - Phone:740-381-1647
Mailing Address - Fax:
Practice Address - Street 1:68200 JENNY LYNN DR
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:OH
Practice Address - Zip Code:43718-9444
Practice Address - Country:US
Practice Address - Phone:740-381-1647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant