Provider Demographics
NPI:1497073761
Name:HEINE, KELLY A (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:HEINE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:KEGLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51502-1988
Mailing Address - Country:US
Mailing Address - Phone:712-322-5565
Mailing Address - Fax:712-322-5566
Practice Address - Street 1:201 RIDGE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4643
Practice Address - Country:US
Practice Address - Phone:712-322-5565
Practice Address - Fax:712-322-5566
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE62406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered