Provider Demographics
NPI:1467697938
Name:EUBANKS, KELLY SUTHER (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUTHER
Last Name:EUBANKS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:CHRISTINE
Other - Last Name:SUTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4500 SAN PABLO RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1865
Mailing Address - Country:US
Mailing Address - Phone:904-953-2000
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9183840163W00000X
FLARNP9183840367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA468126999FMedicaid
FL0007430-00Medicaid
GA468126999AMedicaid
FL0007430-00Medicaid
FLBM627XMedicare PIN
FLBM627ZMedicare PIN
FLBM627YMedicare PIN