Provider Demographics
NPI:1609257005
Name:KAVANAUGH, KELLY (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:NORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710A LEONA ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-2349
Mailing Address - Country:US
Mailing Address - Phone:440-324-0092
Mailing Address - Fax:440-324-0093
Practice Address - Street 1:710A LEONA ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-2349
Practice Address - Country:US
Practice Address - Phone:440-324-0092
Practice Address - Fax:440-324-0093
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17368-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3025372Medicaid
OHH072820Medicare PIN
OHH377600Medicare PIN
OH3025372Medicaid
OHH062060Medicare PIN
OH9389631Medicare PIN