Healthcare Provider Details

I. General information

NPI: 1902301260
Provider Name (Legal Business Name): ALLISON RUTH KELLY RA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N HIGH ST
MOUNT ORAB OH
45154-9158
US

IV. Provider business mailing address

116 N HIGH ST
MOUNT ORAB OH
45154-9158
US

V. Phone/Fax

Practice location:
  • Phone: 937-444-6127
  • Fax:
Mailing address:
  • Phone: 937-444-6127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberRA.161320
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: