Provider Demographics
NPI:1619906336
Name:KELLEN, JAMES J (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:J
Last Name:KELLEN
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2633
Mailing Address - Fax:319-356-2940
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2633
Practice Address - Fax:319-356-2940
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR030050367500000X
IAD078551367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0005855OtherBLUE CROSS OF SD
MN753S5KEOtherMN BLUE CROSS BS
NE460224743-48Medicaid
SD9219547OtherDAKOTACARE
SD5753680Medicaid
SD5753682Medicaid
IA0573923Medicaid
MN796114600Medicaid
MN796114600Medicaid
SD5753680Medicaid
SDS40803Medicare PIN