Individual
KELLY SAMPLE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
12065 NICKI LN, CHARDON, OH 44024-8941
(440) 226-0867
Mailing address
12065 NICKI LN, CHARDON, OH 44024-8941
(440) 226-0867
Taxonomy
Speciality
Code
Description
License number
State
376J00000X
Homemaker
Primary
—
—
Other
Enumeration date
01/08/2021
Last updated
01/08/2021
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