Provider Demographics
NPI:1871587808
Name:CERVENKA, KELLY R (CNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:CERVENKA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10275 CLIPPER CV
Mailing Address - Street 2:
Mailing Address - City:REMINDERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44202-9042
Mailing Address - Country:US
Mailing Address - Phone:330-562-2630
Mailing Address - Fax:
Practice Address - Street 1:4229 PEARL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-4218
Practice Address - Country:US
Practice Address - Phone:216-205-4026
Practice Address - Fax:216-205-4032
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN211663163W00000X
OHCOA.04944-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2343655Medicaid
OHCENP11112Medicare ID - Type Unspecified
OH2343655Medicaid