Provider Demographics
NPI:1942330626
Name:KELLY, TERRI ELLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:ELLEN
Last Name:KELLY
Suffix:
Gender:F
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:PO BOX 3849
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-0849
Mailing Address - Country:US
Mailing Address - Phone:812-234-8261
Mailing Address - Fax:812-234-8262
Practice Address - Street 1:1421 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1005
Practice Address - Country:US
Practice Address - Phone:812-234-8261
Practice Address - Fax:812-234-8262
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28170574A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000508494OtherBLUE CROSS/BLUE SHIELD
IN200853750Medicaid
IN200853750Medicaid