Provider Demographics
NPI:1063236842
Name:KELLY, LARONDA S
Entity type:Individual
Prefix:
First Name:LARONDA
Middle Name:S
Last Name:KELLY
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 1:30225 FORESTGROVE RD
Mailing Address - Street 2:
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-4956
Mailing Address - Country:US
Mailing Address - Phone:216-762-6017
Mailing Address - Fax:
Practice Address - Street 1:30225 FORESTGROVE RD
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-4956
Practice Address - Country:US
Practice Address - Phone:216-762-6017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care