Provider Demographics
NPI:1902584998
Name:KERN, KELLY M
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:KERN
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 1:2529 WALDEN GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45231-1405
Mailing Address - Country:US
Mailing Address - Phone:937-209-0830
Mailing Address - Fax:
Practice Address - Street 1:5525 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-2211
Practice Address - Country:US
Practice Address - Phone:513-398-7609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03443181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist