Provider Demographics
NPI:1467622175
Name:KELLY, KAREN S (CRNA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:S
Last Name:KELLY
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 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6307
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:6101 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-3900
Practice Address - Country:US
Practice Address - Phone:239-304-4862
Practice Address - Fax:239-304-5157
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC222133367500000X
FLARNP9290405367500000X
NY629132367500000X
PARN546418367500000X
FLARNP9483544367500000X
VA0024168373367500000X
OH329661367500000X
SC4172A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCQ623ZMedicare PIN