Provider Demographics
NPI:1659506178
Name:RUST, KELSEY J (CRNA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:J
Last Name:RUST
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:JEAN
Other - Last Name:BETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:92 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2032
Mailing Address - Country:US
Mailing Address - Phone:321-841-4607
Mailing Address - Fax:321-841-4603
Practice Address - Street 1:92 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2032
Practice Address - Country:US
Practice Address - Phone:321-841-4607
Practice Address - Fax:321-841-4603
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3402022367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000961100Medicaid
FLARNP3402022OtherMEDICAL LICENSE
FLCD019ZMedicare PIN