Basic Information
| Provider Information | |||||||||
| NPI: | 1003015546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLINE | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 144 RIGRISH RD | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456629066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407760836 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 144 RIGRISH RD | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456629066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407760836 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2007 | ||||||||
| LastUpdateDate: | 07/14/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN.107186 | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 2294557 | 05 | OH | MEDICAID |