Provider Demographics
NPI:1912095951
Name:KELLY-DAUM, MICHELLE LYNN (CNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:KELLY-DAUM
Suffix:
Gender:F
Credentials:CNP
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Mailing Address - Street 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:216-906-9526
Mailing Address - Fax:866-450-2592
Practice Address - Street 1:1001 LAKESIDE AVE E
Practice Address - Street 2:SUITE 1000
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-1158
Practice Address - Country:US
Practice Address - Phone:216-906-9526
Practice Address - Fax:866-450-2592
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHNP-08540363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNP-08540OtherLICENSE NUMBER
OHNP26551Medicare PIN