Healthcare Provider Details

I. General information

NPI: 1295340701
Provider Name (Legal Business Name): MS. KELLY DIANE MARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 09/11/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3145 STANDISH AVE SW
CANTON OH
44706-3250
US

IV. Provider business mailing address

3145 STANDISH AVE SW
CANTON OH
44706-3250
US

V. Phone/Fax

Practice location:
  • Phone: 330-224-2333
  • Fax:
Mailing address:
  • Phone: 330-224-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: