Provider Demographics
NPI:1194561126
Name:KELLEY, CRYSTAL SUE (RN)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:SUE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4881 SUGAR MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-522-2813
Mailing Address - Fax:937-656-1265
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-522-2813
Practice Address - Fax:937-656-1265
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-08-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OHRN254302163WC0400X, 251B00000X, 364SI0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SI0800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistInformatics
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No251B00000XAgenciesCase Management