Provider Demographics
NPI:1780110676
Name:KELLY, CONSTANCE D (CRNP)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:D
Last Name:KELLY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 639295
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9295
Mailing Address - Country:US
Mailing Address - Phone:248-824-6000
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:7251 ENGLE RD STE 402
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3400
Practice Address - Country:US
Practice Address - Phone:440-826-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASP017456363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA183794Medicare PIN