Provider Demographics
NPI:1962882449
Name:WILKINSON, KELLY A (CNM)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A JANEL
Other - Last Name:SHOCKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3535 PENTAGON BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1705
Mailing Address - Country:US
Mailing Address - Phone:937-429-7350
Mailing Address - Fax:937-431-2623
Practice Address - Street 1:2510 COMMONS BLVD STE 270
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3834
Practice Address - Country:US
Practice Address - Phone:937-431-0200
Practice Address - Fax:937-431-0488
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.16865-NM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0135156Medicaid
OH1184652539OtherGROUP NPI
OH0105065OtherGROUP MEDICAID
OH9934723OtherGROUP PTAN
OH0135156Medicaid
OH34-1689161OtherGROUP TIN