MEDICARE: KELLY MARIE SCHUDER PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0015X	Psychosomatic Medicine Physician	APRN.CNP.0029693	OH

General Provider Information

NPI Number	:	1679209514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MARIE SCHUDER PMHNP

Provider Business Mailing Address
First Line	:	6007 NORWELL DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45449-3111
Country	:	US
Telephone Number	:	937-866-5009
Fax Number	:

Provider Business Practice Location Address
First Line	:	6007 NORWELL DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45449-3111
Country	:	US
Telephone Number	:	937-866-5009
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2022
Last Update Date	:	07/25/2022

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