Healthcare Provider Details

I. General information

NPI: 1568821643
Provider Name (Legal Business Name): KELLIE ANN SHARPE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N HENRY ST
MALINTA OH
43535-9752
US

IV. Provider business mailing address

204 N HENRY ST
MALINTA OH
43535-9752
US

V. Phone/Fax

Practice location:
  • Phone: 419-256-7222
  • Fax: 419-256-6582
Mailing address:
  • Phone: 419-256-7222
  • Fax: 419-256-6582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number154005-M-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: