Provider Demographics
NPI:1902208085
Name:KELLEY GARDNER CRNA, INC
Entity Type:Organization
Organization Name:KELLEY GARDNER CRNA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPLE
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:RHENE
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-286-0137
Mailing Address - Street 1:PO BOX 4518
Mailing Address - Street 2:
Mailing Address - City:STATELINE
Mailing Address - State:NV
Mailing Address - Zip Code:89449-4518
Mailing Address - Country:US
Mailing Address - Phone:866-640-3005
Mailing Address - Fax:866-640-3006
Practice Address - Street 1:7500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5403
Practice Address - Country:US
Practice Address - Phone:916-423-6019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-21
Last Update Date:2014-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2120367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty