Provider Demographics
NPI:1184619306
Name:KELLY, VIRGINIA LANE (CRNA)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LANE
Last Name:KELLY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:LANE
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:9000 EXECUTIVE PARK DRIVE - UPA PHYSICIANS
Mailing Address - Street 2:C200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923
Mailing Address - Country:US
Mailing Address - Phone:865-670-6700
Mailing Address - Fax:865-670-6142
Practice Address - Street 1:2121 MEDICAL CENTRE WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920
Practice Address - Country:US
Practice Address - Phone:606-337-3051
Practice Address - Fax:606-337-2871
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1072826/4024A367500000X
TN14631367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74006362Medicaid
000000276584OtherANTHEM BC&BS
KYP00078424OtherRAILROAD MEDICARE
000000276584OtherANTHEM BC&BS