1962882449 NPI number — KELLY A. WILKINSON CNM

Table of content: KELLY A. WILKINSON CNM (NPI 1962882449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962882449 NPI number — KELLY A. WILKINSON CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKINSON
Provider First Name:
KELLY
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHOCKEY
Provider Other First Name:
KELLY
Provider Other Middle Name:
A. JANEL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962882449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3535 PENTAGON BLVD STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERCREEK
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45431-1705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-429-7350
Provider Business Mailing Address Fax Number:
937-431-2623

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2510 COMMONS BLVD STE 270
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVERCREEK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45431-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-431-0200
Provider Business Practice Location Address Fax Number:
937-431-0488
Provider Enumeration Date:
06/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  COA.16865-NM , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0135156 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1184652539 . This is a "GROUP NPI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0105065 . This is a "GROUP MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 9934723 . This is a "GROUP PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 111580300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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