Provider Demographics
NPI:1942265244
Name:KELLY, CHRISTOPHER PAUL (CRNA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:PAUL
Last Name:KELLY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-3121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:161 MOUNT PELIA RD
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3811
Practice Address - Country:US
Practice Address - Phone:731-588-0001
Practice Address - Fax:731-587-2775
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN 96601367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3631898Medicaid
TN4047865OtherBLUE CROSS/BLUE SHIELD TN
TN3631898Medicare ID - Type Unspecified