Provider Demographics
NPI:1205308657
Name:HRIESIK, KELLY (CNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HRIESIK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 BURGER AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2028
Mailing Address - Country:US
Mailing Address - Phone:419-512-0944
Mailing Address - Fax:
Practice Address - Street 1:990 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2246
Practice Address - Country:US
Practice Address - Phone:419-756-6111
Practice Address - Fax:419-756-2549
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.302617163W00000X
OHAPRN.CNP.024106363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse