Provider Demographics
NPI:1033200027
Name:PETZ, KELLY N (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:PETZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:S
Other - Last Name:NEVINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:23955 MILL COVE RD
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-3576
Mailing Address - Country:US
Mailing Address - Phone:301-737-1430
Mailing Address - Fax:
Practice Address - Street 1:1001 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4453
Practice Address - Country:US
Practice Address - Phone:800-394-4445
Practice Address - Fax:706-955-0720
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001191107367500000X
MD127961367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered