Provider Demographics
NPI:1386025245
Name:WOODS, KELLIE MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:WOODS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7502 STATE RD
Mailing Address - Street 2:STE 2290
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255-2800
Mailing Address - Country:US
Mailing Address - Phone:615-425-4200
Mailing Address - Fax:
Practice Address - Street 1:7502 STATE RD
Practice Address - Street 2:STE 2290
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-2800
Practice Address - Country:US
Practice Address - Phone:615-425-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.17455-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0135929Medicaid
OH0135929Medicaid