Provider Demographics
NPI:1427738152
Name:FLACK, KALIE NICOLE (PA)
Entity type:Individual
Prefix:
First Name:KALIE
Middle Name:NICOLE
Last Name:FLACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 77
Mailing Address - Street 2:
Mailing Address - City:LITHOPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:43136-0077
Mailing Address - Country:US
Mailing Address - Phone:614-493-6291
Mailing Address - Fax:
Practice Address - Street 1:600 N PICKAWAY ST
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1447
Practice Address - Country:US
Practice Address - Phone:740-474-2126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.008418RX363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program