Healthcare Provider Details

I. General information

NPI: 1356971824
Provider Name (Legal Business Name): KELLY HURST PMHMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3142 BATES RD
MADISON OH
44057-9727
US

IV. Provider business mailing address

3142 BATES RD
MADISON OH
44057-9727
US

V. Phone/Fax

Practice location:
  • Phone: 440-307-0289
  • Fax: 440-417-1644
Mailing address:
  • Phone: 440-307-0289
  • Fax: 440-417-1644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN.382670
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN.368487
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: