Provider Demographics
NPI:1356392153
Name:KELLY, KATHLEEN MARIE (CRNA, RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN MARIE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:CRNA, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GREENHORN DR
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9682
Mailing Address - Country:US
Mailing Address - Phone:719-510-5339
Mailing Address - Fax:
Practice Address - Street 1:400 GREENHORN DR
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9682
Practice Address - Country:US
Practice Address - Phone:719-510-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK8810163W00000X
CA216502163W00000X
OR096007749RN163W00000X
WARN00125197163W00000X
CO66699367500000X, 367500000X
AK139367500000X
AZCRNA0350367500000X
CA1483367500000X
NMR28085367500000X
OR200660008CRNA367500000X
TX587367367500000X
WAAP30006979367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse