Healthcare Provider Details

I. General information

NPI: 1922084425
Provider Name (Legal Business Name): KELLY ANN SHANK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 BRIARFIELD BLVD STE 300
MAUMEE OH
43537-9502
US

IV. Provider business mailing address

801 ROSEHILL RD
JACKSON MI
49202-1762
US

V. Phone/Fax

Practice location:
  • Phone: 419-452-2140
  • Fax: 419-873-6327
Mailing address:
  • Phone: 517-212-2008
  • Fax: 517-212-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN261639
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: