Basic Information
Provider Information | |||||||||
NPI: | 1962882449 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILKINSON | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHOCKEY | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | A. JANEL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3535 PENTAGON BLVD STE 220 | ||||||||
Address2: |   | ||||||||
City: | BEAVERCREEK | ||||||||
State: | OH | ||||||||
PostalCode: | 454311705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9374297350 | ||||||||
FaxNumber: | 9374312623 | ||||||||
Practice Location | |||||||||
Address1: | 1067 HAGER ST | ||||||||
Address2: | GRAND LAKE OB/GYN | ||||||||
City: | SAINT MARYS | ||||||||
State: | OH | ||||||||
PostalCode: | 458852422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193943387 | ||||||||
FaxNumber: | 4193947313 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2015 | ||||||||
LastUpdateDate: | 11/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | COA.16865-NM | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 9934723 | 01 | OH | GROUP PTAN | OTHER | 0105065 | 01 | OH | GROUP MEDICAID | OTHER | 0135156 | 05 | OH |   | MEDICAID | 1184652539 | 01 | OH | GROUP NPI | OTHER |