Basic Information
| Provider Information | |||||||||
| NPI: | 1366039935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SLAVIK-BOSWORTH | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 EDGEFIELD BLVD | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433025801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409144178 | ||||||||
| FaxNumber: | 7403862640 | ||||||||
| Practice Location | |||||||||
| Address1: | 36000 DETROIT RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440111641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409378074 | ||||||||
| FaxNumber: | 4409378725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2020 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.0028216 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.