Provider Demographics
NPI:1740890201
Name:KING, KELLIE (APRN)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-2545
Mailing Address - Country:US
Mailing Address - Phone:440-785-4769
Mailing Address - Fax:
Practice Address - Street 1:7575 NORTHCLIFF AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-3267
Practice Address - Country:US
Practice Address - Phone:440-785-4769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-08
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2019081900363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health