Provider Demographics
NPI:1427075415
Name:SIEGEL, KELLY A (CNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9485 MENTOR AVE SUITE 210
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060
Mailing Address - Country:US
Mailing Address - Phone:440-255-5571
Mailing Address - Fax:
Practice Address - Street 1:9485 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-1716
Practice Address - Country:US
Practice Address - Phone:440-255-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-04339363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2160683Medicaid
OH000000224469OtherUNISON
OH000000539712OtherANTHEM
OH740018OtherBUCKEYE
OH746018OtherBUCKEYE
OH364120OtherWELLCARE
7240712OtherAETNA
OH364120OtherWELLCARE
S97598Medicare UPIN
WENP04892Medicare PIN