=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245398353
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY RADER WHALEY DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 03/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 LARIMAR DR
-----------------------------------------------------
City | WILLOWICK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44095-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-229-0292
-----------------------------------------------------
Fax | 440-975-1963
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 182
-----------------------------------------------------
City | WICKLIFFE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44092-0182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-229-0292
-----------------------------------------------------
Fax | 440-975-1963
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 3068
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------