Provider Demographics
NPI:1598776858
Name:KELLY, STEPHANIE C (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:C
Other - Last Name:HOAG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:185 PENNY AVE
Mailing Address - Street 2:
Mailing Address - City:EAST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-1454
Mailing Address - Country:US
Mailing Address - Phone:847-836-7015
Mailing Address - Fax:
Practice Address - Street 1:2900 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5640
Practice Address - Country:US
Practice Address - Phone:773-665-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041258087367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL98831Medicare ID - Type Unspecified