Healthcare Provider Details

I. General information

NPI: 1093453862
Provider Name (Legal Business Name): KELLY NICOLE GUTHRIE PA-C, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 07/28/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3188 BELLEVUE AVE
CINCINNATI OH
45219-2369
US

IV. Provider business mailing address

9721 TIMBERVIEW CT
WEST CHESTER OH
45241-3687
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8500
  • Fax: 513-584-8554
Mailing address:
  • Phone: 513-226-8523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007572RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: