Provider Demographics
NPI:1578527123
Name:KELLEY, VINCENT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:
Last Name:KELLEY
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 1:102 HOSPITAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:DONALSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:39845
Mailing Address - Country:US
Mailing Address - Phone:229-524-5217
Mailing Address - Fax:229-524-8217
Practice Address - Street 1:102 HOSPITAL CIRCLE
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845
Practice Address - Country:US
Practice Address - Phone:229-524-5217
Practice Address - Fax:229-524-8217
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA141881367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q14087Medicare UPIN
43ZCBXJ03Medicare ID - Type Unspecified