Provider Demographics
NPI:1821012758
Name:KELLY, KATHLEEN MARIE (CRNA, RN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:CRNA, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 11TH ST SE
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-9114
Mailing Address - Country:US
Mailing Address - Phone:541-347-2426
Mailing Address - Fax:541-347-3923
Practice Address - Street 1:900 11TH ST SE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9114
Practice Address - Country:US
Practice Address - Phone:541-347-2426
Practice Address - Fax:541-347-3923
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR044645367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
R13881Medicare UPIN