Provider Demographics
NPI:1083817787
Name:CALVIN, KELLY DAWN (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DAWN
Last Name:CALVIN
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 1:125 TIMBERLEE DR
Mailing Address - Street 2:
Mailing Address - City:EVANS CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16033-3931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 J D ANDERSON DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3494
Practice Address - Country:US
Practice Address - Phone:800-394-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN532423367500000X
WV71258367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009910Medicaid
WV0207026000Medicaid
WV3810009910Medicaid
WV9333201Medicare PIN
WV$$$$$$$$$00OtherOHIO WORKERS COMP
WV3810009910Medicaid
WV0207026000Medicaid