Provider Demographics
NPI:1366109498
Name:BOGGS, KELLY DANIELLE (CNP)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:DANIELLE
Last Name:BOGGS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:635 SARATOGA ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-1920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10506 MONTGOMERY RD STE 301A
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4400
Practice Address - Country:US
Practice Address - Phone:513-246-2400
Practice Address - Fax:513-246-4050
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP.0030319363LA2100X
OHAPRN.CNP.0030319363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0462231Medicaid