Provider Demographics
NPI:1497732903
Name:SIMPSON, KELLY SHAUN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:SHAUN
Last Name:SIMPSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 PARKSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8706
Mailing Address - Country:US
Mailing Address - Phone:850-830-5525
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER ATTN: CREDENTIALS OFFICE
Practice Address - Street 2:9040 JACKSON AVE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431
Practice Address - Country:US
Practice Address - Phone:253-969-2252
Practice Address - Fax:235-968-3278
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN309540367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered