Healthcare Provider Details

I. General information

NPI: 1497618912
Provider Name (Legal Business Name): KELLY ELY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 S SOUTH ST
WILMINGTON OH
45177-2755
US

IV. Provider business mailing address

2625 SHAFOR BLVD APT 4
OAKWOOD OH
45419-1635
US

V. Phone/Fax

Practice location:
  • Phone: 937-910-6218
  • Fax: 800-480-7578
Mailing address:
  • Phone: 937-681-2675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: