Provider Demographics
NPI:1811035231
Name:MAUGHON, KELLEY L (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:L
Last Name:MAUGHON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:L
Other - Last Name:MUNROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 511
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-0511
Mailing Address - Country:US
Mailing Address - Phone:573-406-1301
Mailing Address - Fax:573-406-0511
Practice Address - Street 1:98 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6885
Practice Address - Country:US
Practice Address - Phone:573-406-1301
Practice Address - Fax:573-406-0511
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6003A367500000X
MO2002022036367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO175118OtherMO BLUE SHIELD
AR83410OtherARK BLUE SHIELD
MO917229908Medicaid
AR158119001Medicaid
MO827563268Medicare PIN