Provider Demographics
NPI:1982016754
Name:OSBORN, KELLY (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:OSBORN
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 1:309 WEST ST
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:IA
Mailing Address - Zip Code:51640-1873
Mailing Address - Country:US
Mailing Address - Phone:712-382-1039
Mailing Address - Fax:
Practice Address - Street 1:26136 US HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:MO
Practice Address - Zip Code:64446-9105
Practice Address - Country:US
Practice Address - Phone:660-686-2325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014013824367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered