Provider Demographics
NPI:1457403313
Name:KELLY, KRISTEN (CRNA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:KELLY
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 1:55 SCHANCK RD
Mailing Address - Street 2:SUITE 8A
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2964
Mailing Address - Country:US
Mailing Address - Phone:732-431-9544
Mailing Address - Fax:732-431-9313
Practice Address - Street 1:55 SCHANCK RD
Practice Address - Street 2:SUITE 8A
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2964
Practice Address - Country:US
Practice Address - Phone:732-431-9544
Practice Address - Fax:732-431-9313
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR08801200367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ016539PJNOtherMEDICARE NUMBER
NJ016539A01Medicare PIN
NJ016539Medicare PIN