Provider Demographics
NPI:1598899361
Name:GOODWIN, KELLIE J (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:J
Last Name:GOODWIN
Suffix:
Gender:F
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:PO BOX 10484
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-0484
Mailing Address - Country:US
Mailing Address - Phone:205-322-1808
Mailing Address - Fax:205-322-1851
Practice Address - Street 1:400 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-4716
Practice Address - Country:US
Practice Address - Phone:205-322-1808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-066446367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered