Basic Information
| Provider Information | |||||||||
| NPI: | 1376058701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLIS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192512032 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 W MCCREIGHT AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455041890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373231404 | ||||||||
| FaxNumber: | 9373231407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2017 | ||||||||
| LastUpdateDate: | 05/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRNCNP021736 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.