Healthcare Provider Details

I. General information

NPI: 1154395267
Provider Name (Legal Business Name): JOSEPH ANTHONY KELLY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL JACKSONVILLE 2080 CHILD ST
JACKSONVILLE FL
32214-0001
US

IV. Provider business mailing address

1706 EAGLE WATCH DR
ORANGE PARK FL
32003-8637
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7856
  • Fax: 904-542-9114
Mailing address:
  • Phone: 904-215-8068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN282245L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: