Provider Demographics
NPI:1467818542
Name:KELLY, KATHLEEN E (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:KELLY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:E
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:PO BOX 1123
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:800-516-5315
Mailing Address - Fax:
Practice Address - Street 1:801 OSTRUM ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1065
Practice Address - Country:US
Practice Address - Phone:610-954-5810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN588096367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered