Provider Demographics
NPI:1457948804
Name:KELLY, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-2005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:440-826-3830
Practice Address - Street 1:5800 LANDERBROOK DR STE 250
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-4047
Practice Address - Country:US
Practice Address - Phone:440-646-1600
Practice Address - Fax:440-646-1505
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH50.00763RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program