Provider Demographics
NPI:1427513795
Name:MCCOCKRAN, KELLY M (APRN, CNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:MCCOCKRAN
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 W RAHN RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2219
Mailing Address - Country:US
Mailing Address - Phone:937-433-8990
Mailing Address - Fax:937-433-8691
Practice Address - Street 1:33 W RAHN RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2219
Practice Address - Country:US
Practice Address - Phone:937-433-8990
Practice Address - Fax:937-433-8691
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.335087163W00000X
OHAPRN.CNP.024227363L00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner