Healthcare Provider Details

I. General information

NPI: 1265627889
Provider Name (Legal Business Name): KELLY J KANZEG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 TOWNSHIP ROAD 581
SULLIVAN OH
44880-9767
US

IV. Provider business mailing address

319 TOWNSHIP ROAD 581
SULLIVAN OH
44880-9767
US

V. Phone/Fax

Practice location:
  • Phone: 330-421-6844
  • Fax:
Mailing address:
  • Phone: 330-421-6844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number098645
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: