Basic Information
| Provider Information | |||||||||
| NPI: | 1730453911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEELY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ALISSA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373844841 | ||||||||
| FaxNumber: | 9375227626 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958646 | ||||||||
| FaxNumber: | 9373958697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2012 | ||||||||
| LastUpdateDate: | 03/20/2012 | ||||||||
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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 | 363A00000X | 50003466 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.