Provider Demographics
NPI:1285187542
Name:CARLSON, KELLY (NP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:EASTHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8989 WINTON ROAD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45231-3817
Mailing Address - Country:US
Mailing Address - Phone:513-761-2776
Mailing Address - Fax:513-679-4866
Practice Address - Street 1:8989 WINTON ROAD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45231-3817
Practice Address - Country:US
Practice Address - Phone:513-761-2776
Practice Address - Fax:513-679-4866
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010659363LF0000X
OHAPRN.CNP.019496363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0181792Medicaid
KY7100425980Medicaid