Provider Demographics
NPI:1184685000
Name:WHITLOW, KELLY S (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:WHITLOW
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 1:4901 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5935
Mailing Address - Country:US
Mailing Address - Phone:850-477-7042
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:5151 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8721
Practice Address - Country:US
Practice Address - Phone:850-416-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1089940367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1772321Medicaid
FL306782300Medicaid
AL51526568OtherBLUE CROSS BLUE SHIELD
AL009985275Medicaid
GA229991328AMedicaid
051526568Medicare ID - Type Unspecified
LA1772321Medicaid