Provider Demographics
NPI:1801238084
Name:KELLAR, DIANA MARIE (MSN)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:KELLAR
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636988
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6988
Mailing Address - Country:US
Mailing Address - Phone:888-940-2722
Mailing Address - Fax:513-632-8898
Practice Address - Street 1:341 YOUNGSTOWN KINGSVILLE RD SE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:OH
Practice Address - Zip Code:44473-9601
Practice Address - Country:US
Practice Address - Phone:330-394-2305
Practice Address - Fax:330-394-1405
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA14840NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0098717Medicaid