Provider Demographics
NPI:1356455075
Name:BIRCH, KELLIE K (CRNA)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:K
Last Name:BIRCH
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 1:9500 S DADELAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2866
Mailing Address - Country:US
Mailing Address - Phone:786-530-3820
Mailing Address - Fax:
Practice Address - Street 1:11011 SHERIDAN ST STE 106
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-1501
Practice Address - Country:US
Practice Address - Phone:954-435-0101
Practice Address - Fax:954-435-0125
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11010950367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117705200Medicaid
TX132854409Medicaid
TX88295UOtherBCBS
TX8B5259Medicare ID - Type UnspecifiedPROVIDER #
TX88295UOtherBCBS
TX8L10342Medicare PIN