Provider Demographics
NPI:1508301805
Name:MOSS, KELSEY VERA (CRNA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:VERA
Last Name:MOSS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:VERA
Other - Last Name:RUNNALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4413
Practice Address - Country:US
Practice Address - Phone:518-926-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-23
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY631978163W00000X, 367500000X
NC291293367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse