Provider Demographics
NPI:1356722904
Name:KELLY, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:KELLY
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 1:11131 NAOMI DR
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44130-1555
Mailing Address - Country:US
Mailing Address - Phone:330-410-3762
Mailing Address - Fax:
Practice Address - Street 1:11131 NAOMI DR
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44130-1555
Practice Address - Country:US
Practice Address - Phone:330-410-3762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH283XC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283XC2000XHospitalsRehabilitation HospitalChildren