Provider Demographics
NPI:1174052567
Name:KEITH, KELLY LYNNE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNNE
Last Name:KEITH
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 1:121 W HERRICK AVE
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44090-1239
Mailing Address - Country:US
Mailing Address - Phone:440-752-1078
Mailing Address - Fax:
Practice Address - Street 1:121 W HERRICK AVE
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:OH
Practice Address - Zip Code:44090
Practice Address - Country:US
Practice Address - Phone:440-752-1078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN356616163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse