Healthcare Provider Details

I. General information

NPI: 1295008506
Provider Name (Legal Business Name): KRISTIE KELLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PINE AVE SE
WARREN OH
44483-6524
US

IV. Provider business mailing address

535 MARMION AVE
YOUNGSTOWN OH
44502-2323
US

V. Phone/Fax

Practice location:
  • Phone: 330-393-0598
  • Fax:
Mailing address:
  • Phone: 330-782-5664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number138093
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: