Basic Information
Provider Information | |||||||||
NPI: | 1194282269 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PATTERSON | ||||||||
FirstName: | KELSEY | ||||||||
MiddleName: | LINNETTE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PRIODE | ||||||||
OtherFirstName: | KELSEY | ||||||||
OtherMiddleName: | LINNETTE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6680 POE AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 454142855 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372808400 | ||||||||
FaxNumber: | 9372456308 | ||||||||
Practice Location | |||||||||
Address1: | 2350 MIAMI VALLEY DR STE 500 | ||||||||
Address2: |   | ||||||||
City: | CENTERVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 454594780 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372931622 | ||||||||
FaxNumber: | 9372456308 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/25/2019 | ||||||||
LastUpdateDate: | 01/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.024333 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X | APRN.CNP.024333 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 0339309 | 05 | OH |   | MEDICAID |