Provider Demographics
NPI:1063149839
Name:DIMARZIO, KELSEY ELLEN
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ELLEN
Last Name:DIMARZIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51315 GOLFVIEW CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-6502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30830 OLD US 20
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-9481
Practice Address - Country:US
Practice Address - Phone:574-674-5730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029868A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist