Provider Demographics
NPI:1912730136
Name:MATHIS, KELSEY A
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:A
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 COLONEL GLENN HWY
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45324-2029
Mailing Address - Country:US
Mailing Address - Phone:859-630-0825
Mailing Address - Fax:
Practice Address - Street 1:3640 COLONEL GLENN HWY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45435-2517
Practice Address - Country:US
Practice Address - Phone:859-630-0825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program