Provider Demographics
NPI:1346590361
Name:KELLY, MARTHA SUZANNE (FNP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:SUZANNE
Last Name:KELLY
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:SUZANNE
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:7171 KECK PARK CIR NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-6301
Mailing Address - Country:US
Mailing Address - Phone:330-498-8200
Mailing Address - Fax:
Practice Address - Street 1:7171 KECK PARK CIR NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-6301
Practice Address - Country:US
Practice Address - Phone:330-498-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.397302163W00000X
OHAPRN.CNP.0027774363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH164W00000XMedicaid