Provider Demographics
NPI:1669821716
Name:KIES, KELSEY (CNP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:KIES
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:KRESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:1 MEDICAL CENTER DR FL 3
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45005
Practice Address - Country:US
Practice Address - Phone:513-974-6093
Practice Address - Fax:513-974-5005
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH019641363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0172890Medicaid