Provider Demographics
NPI:1316522337
Name:KELLY, IESHA THERESA (LPN)
Entity type:Individual
Prefix:
First Name:IESHA
Middle Name:THERESA
Last Name:KELLY
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22501 LAKEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1623
Mailing Address - Country:US
Mailing Address - Phone:216-704-8696
Mailing Address - Fax:
Practice Address - Street 1:5711 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-3332
Practice Address - Country:US
Practice Address - Phone:216-415-2150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6724251J00000X, 376K00000X
OHLPN.185135164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No251J00000XAgenciesNursing Care
No376K00000XNursing Service Related ProvidersNurse's Aide