Provider Demographics
NPI:1720447352
Name:EDWARDS, KELLY (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EDWARDS
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 1:11408 GOLDEN BAY PL
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34211-3404
Mailing Address - Country:US
Mailing Address - Phone:540-597-7021
Mailing Address - Fax:
Practice Address - Street 1:3333 CATTLEMEN RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-6056
Practice Address - Country:US
Practice Address - Phone:540-597-7021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173261367500000X
FL11007072367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered