MEDICARE: CORINA V KELLEY MSN, ANP

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	363L00000X	Nurse Practitioner	APRN.CNP.023758	OH
2	363LA2200X	Adult Health Nurse Practitioner	APRN.CNP.023758	OH

General Provider Information

NPI Number	:	1699241026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORINA V KELLEY MSN, ANP

Provider Business Mailing Address
First Line	:	11201 SHAKER BLVD STE 240
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-3873
Country	:	US
Telephone Number	:	216-791-0017
Fax Number	:	216-791-0021

Provider Business Practice Location Address
First Line	:	11201 SHAKER BLVD STE 240
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-3873
Country	:	US
Telephone Number	:	216-791-0017
Fax Number	:	216-791-0021

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

Provider Enumeration Date	:	10/24/2018
Last Update Date	:	10/24/2018

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