Basic Information
| Provider Information | |||||||||
| NPI: | 1386082923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STRALEY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | JAE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 FOX RD | ||||||||
| Address2: | |||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458912475 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 140 FOX RD | ||||||||
| Address2: | |||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458912475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192325279 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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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 | 363LF0000X | COA14689NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | RN.334650 | OH | N | Nursing Service Providers | Registered Nurse | 363LX0106X | COA14689-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Occupational Health |
ID Information
| ID | Type | State | Issuer | Description | 0090042 | 05 | OH | MEDICAID |