Provider Demographics
NPI:1003087776
Name:KELLY, THERESA A (CRNA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
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 49
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15230-0049
Mailing Address - Country:US
Mailing Address - Phone:570-647-4381
Mailing Address - Fax:
Practice Address - Street 1:601 PARK ST
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1445
Practice Address - Country:US
Practice Address - Phone:570-647-4381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN298133L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00952243OtherRR MEDICARE
PA043077YETGMedicare PIN
PA043077Medicare PIN