Provider Demographics
NPI:1134562424
Name:FLORES, KELLY (CRNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FLORES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:WINDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:611 W PARK STREET
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-3311
Mailing Address - Fax:
Practice Address - Street 1:611 W. PARK STREET
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3303
Practice Address - Fax:217-383-3265
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010336367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3270801Medicare PIN