Provider Demographics
NPI:1023199353
Name:EDWARDS, KELLY D (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MORRIS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1326
Mailing Address - Country:US
Mailing Address - Phone:304-647-6006
Mailing Address - Fax:
Practice Address - Street 1:501 MORRIS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1326
Practice Address - Country:US
Practice Address - Phone:304-647-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV49422367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1064251OtherWORKERS' COMP
OH2475674Medicaid
WV2701385000Medicaid
KY74007865Medicaid
WVP00209268Medicare PIN
WV8228992Medicare PIN
P40242Medicare UPIN