Provider Demographics
NPI:1194165795
Name:GILLETLY, KAY M (RN CDMS CRRN CCM MSC)
Entity type:Individual
Prefix:
First Name:KAY
Middle Name:M
Last Name:GILLETLY
Suffix:
Gender:F
Credentials:RN CDMS CRRN CCM MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-0131
Mailing Address - Country:US
Mailing Address - Phone:614-975-6773
Mailing Address - Fax:
Practice Address - Street 1:76 COTTSWOLD DR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-2812
Practice Address - Country:US
Practice Address - Phone:614-975-6773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN127610171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator