Provider Demographics
NPI:1477887107
Name:CANTWELL, KELLY M (CRNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:CANTWELL
Suffix:
Gender:
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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-791-2203
Mailing Address - Fax:
Practice Address - Street 1:2720 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4810
Practice Address - Country:US
Practice Address - Phone:803-935-8538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA95000765367500000X
SC76993390200000X
SC4081367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN2026Medicaid
SCAN2026Medicaid