Provider Demographics
NPI:1598814568
Name:MARX, KELLY S (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:MARX
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:S
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-4562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-006356367500000X
MERNA103011367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001868901Medicare PIN