Healthcare Provider Details

I. General information

NPI: 1427563345
Provider Name (Legal Business Name): MARY E KELTY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 HIGH ST NE
WARREN OH
44481-1222
US

IV. Provider business mailing address

8255 SOUTH AVE
YOUNGSTOWN OH
44512-6483
US

V. Phone/Fax

Practice location:
  • Phone: 330-318-3871
  • Fax:
Mailing address:
  • Phone: 330-318-3830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.120261.MEDS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: