Provider Demographics
NPI:1013313154
Name:KELLEY, MARK ALLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:KELLEY
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 1:411 GAMBREL ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-8687
Mailing Address - Country:US
Mailing Address - Phone:615-480-3826
Mailing Address - Fax:
Practice Address - Street 1:1818 ALBION ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-2918
Practice Address - Country:US
Practice Address - Phone:615-341-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19539367500000X
TN174012163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse