Provider Demographics
NPI:1669812111
Name:FIACK, KELLY J (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:FIACK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:141 N MAIN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-2055
Mailing Address - Country:US
Mailing Address - Phone:207-992-4032
Mailing Address - Fax:207-992-4034
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-992-4032
Practice Address - Fax:207-992-4034
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MERNA133018367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered