Healthcare Provider Details

I. General information

NPI: 1003456286
Provider Name (Legal Business Name): KELLEY MAMEDE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S STATE ST
MARION OH
43302-5000
US

IV. Provider business mailing address

70 BUR REED RD
DELAWARE OH
43015-3676
US

V. Phone/Fax

Practice location:
  • Phone: 740-387-0650
  • Fax:
Mailing address:
  • Phone: 330-620-9432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: