Provider Demographics
NPI:1043041585
Name:DIXON, KELLY JOANN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JOANN
Last Name:DIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND DALE
Mailing Address - State:OH
Mailing Address - Zip Code:45673-9728
Mailing Address - Country:US
Mailing Address - Phone:740-649-4535
Mailing Address - Fax:
Practice Address - Street 1:316 MARKET ST
Practice Address - Street 2:
Practice Address - City:RICHMOND DALE
Practice Address - State:OH
Practice Address - Zip Code:45673-9728
Practice Address - Country:US
Practice Address - Phone:740-649-4535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN061751347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle