Provider Demographics
NPI:1063791226
Name:KELLEY, JULIE MARIE (LPN)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4978 S ELYRIA RD
Mailing Address - Street 2:
Mailing Address - City:SHREVE
Mailing Address - State:OH
Mailing Address - Zip Code:44676-9238
Mailing Address - Country:US
Mailing Address - Phone:330-201-4111
Mailing Address - Fax:
Practice Address - Street 1:4978 S ELYRIA RD
Practice Address - Street 2:
Practice Address - City:SHREVE
Practice Address - State:OH
Practice Address - Zip Code:44676-9238
Practice Address - Country:US
Practice Address - Phone:330-201-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN120341-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse