Provider Demographics
NPI:1609617935
Name:WANDERSEE, KELLY JO (CCMA,CNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:WANDERSEE
Suffix:
Gender:F
Credentials:CCMA,CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43605-2810
Mailing Address - Country:US
Mailing Address - Phone:419-598-6822
Mailing Address - Fax:
Practice Address - Street 1:541 MILTON ST APT 2
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43605-2669
Practice Address - Country:US
Practice Address - Phone:419-508-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty