Provider Demographics
NPI:1487903712
Name:KELLEY, MARY ELLEN (RN,CNS)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN,CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5141 MICHAEL ANTHONY LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7945
Mailing Address - Country:US
Mailing Address - Phone:513-574-6135
Mailing Address - Fax:
Practice Address - Street 1:5141 MICHAEL ANTHONY LN
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247-7945
Practice Address - Country:US
Practice Address - Phone:513-574-6135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA05921-NS364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist