Provider Demographics
NPI:1770728149
Name:THOMAS, KELLEY LYNN (CRNA)
Entity type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:LYNN
Last Name:THOMAS
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-852-8266
Mailing Address - Fax:502-852-3762
Practice Address - Street 1:530 S. JACKSON STREET
Practice Address - Street 2:ROOM C2A01
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-852-8266
Practice Address - Fax:502-852-3762
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005906367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100075180Medicaid
KY0259208Medicare PIN