Provider Demographics
NPI:1285839282
Name:KELLEY, GRACE (CRNA, APRN)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CRNA, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLOCK TOWER COMMONS
Mailing Address - Street 2:ROUTE 22
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-4055
Mailing Address - Country:US
Mailing Address - Phone:845-592-4919
Mailing Address - Fax:845-279-5168
Practice Address - Street 1:140 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2505
Practice Address - Country:US
Practice Address - Phone:203-757-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE57685163W00000X
CT003750367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTE57685OtherRN LICENCES