Provider Demographics
NPI:1093521114
Name:KELLY, TISHA MARIE (STNA)
Entity type:Individual
Prefix:MRS
First Name:TISHA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 ESSEX RD
Mailing Address - Street 2:
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-2234
Mailing Address - Country:US
Mailing Address - Phone:440-653-1452
Mailing Address - Fax:
Practice Address - Street 1:272 ESSEX RD
Practice Address - Street 2:
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089-2234
Practice Address - Country:US
Practice Address - Phone:440-653-1452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH602887461024376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide