Provider Demographics
NPI:1376887299
Name:RADFORD, KELLY L (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:RADFORD
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:BEDFORD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60499-0936
Mailing Address - Country:US
Mailing Address - Phone:708-326-1637
Mailing Address - Fax:708-326-1671
Practice Address - Street 1:301 MADISON ST
Practice Address - Street 2:SUITE 306
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6549
Practice Address - Country:US
Practice Address - Phone:708-326-1637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010013367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered