Provider Demographics
NPI:1952777930
Name:SPRAGUE, KELLY J (LMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2174 SAWBURY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1856
Mailing Address - Country:US
Mailing Address - Phone:614-738-5079
Mailing Address - Fax:
Practice Address - Street 1:100 FRANKFORT SQ
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-1058
Practice Address - Country:US
Practice Address - Phone:614-738-5079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33-016869171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor