Provider Demographics
NPI:1417306838
Name:KELLEY, BETHANY A (CRNA)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:A
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111
Practice Address - Country:US
Practice Address - Phone:816-932-3679
Practice Address - Fax:816-932-9089
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7009-33367500000X
IL209021707367500000X
MO2010026479367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMULTISPECIALTY GROUP PTAN