Provider Demographics
NPI:1376501395
Name:KELLEY, TIMOTHY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 JEFFERSON AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:877 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2807
Practice Address - Country:US
Practice Address - Phone:901-448-5893
Practice Address - Fax:901-448-5540
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10994367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3628056Medicaid
TN3628056Medicaid