Basic Information
| Provider Information | |||||||||
| NPI: | 1225767015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | GREY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3533 SOUTHERN BLVD STE 2100 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958556 | ||||||||
| FaxNumber: | 9373956376 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372984331 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2022 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.