Provider Demographics
NPI:1902310618
Name:KELLY, SHAWDARE MIRIAM (FNP)
Entity Type:Individual
Prefix:MS
First Name:SHAWDARE
Middle Name:MIRIAM
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:OH
Mailing Address - Zip Code:43821-9782
Mailing Address - Country:US
Mailing Address - Phone:740-624-8563
Mailing Address - Fax:
Practice Address - Street 1:914 HIGH ST
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:OH
Practice Address - Zip Code:43821-9782
Practice Address - Country:US
Practice Address - Phone:740-624-8563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily