Healthcare Provider Details

I. General information

NPI: 1588136329
Provider Name (Legal Business Name): KELLIE BLAUMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12041 RAVENNA RD
CHARDON OH
44024-7008
US

IV. Provider business mailing address

12041 RAVENNA RD
CHARDON OH
44024-7008
US

V. Phone/Fax

Practice location:
  • Phone: 440-286-7154
  • Fax: 440-286-1037
Mailing address:
  • Phone: 440-286-7154
  • Fax: 440-286-1037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: