Provider Demographics
NPI:1770159881
Name:BURNS, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BURNS
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 1:10165 RUSSWILL LN
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:KY
Mailing Address - Zip Code:41091-9572
Mailing Address - Country:US
Mailing Address - Phone:859-803-5641
Mailing Address - Fax:
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-29
Last Update Date:2021-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0028510363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner