MEDICARE: KELLIE CLAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	477656	OH
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0035099	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	APRN.CNP.0035099	OTHER	OH	STATE LICENSE

General Provider Information

NPI Number	:	1043766769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE CLAY

Provider Business Mailing Address
First Line	:	1824 BRIARROSE CT
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45231-1907
Country	:	US
Telephone Number	:	513-520-4100
Fax Number	:

Provider Business Practice Location Address
First Line	:	44 S SOUDER AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43222-1535
Country	:	US
Telephone Number	:	574-546-1900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	03/13/2024

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Directions to “ KELLIE CLAY ” Practice Location

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