Healthcare Provider Details

I. General information

NPI: 1487193132
Provider Name (Legal Business Name): KELLY KRIKLAVA P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 03/20/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE, ML 1013
CINCINNATI OH
45229
US

IV. Provider business mailing address

PO BOX 417
STUART FL
34995-0417
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4466
  • Fax: 513-636-5846
Mailing address:
  • Phone: 772-781-2799
  • Fax: 772-781-2716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006386
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111155
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4542
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007959RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: