Provider Demographics
NPI:1659321081
Name:KELLY, CYNTHIA B (CRNA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:B
Last Name:KELLY
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 1:6863 STAFFORDSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4107
Mailing Address - Country:US
Mailing Address - Phone:713-790-8089
Mailing Address - Fax:
Practice Address - Street 1:6400 FANNIN ST
Practice Address - Street 2:SUITE 1500
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1521
Practice Address - Country:US
Practice Address - Phone:832-325-7321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX689611174400000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOOY394OtherGROUP
TX689611OtherNURSING LICENSE
TX689611OtherNURSING LICENSE