Healthcare Provider Details

I. General information

NPI: 1720447352
Provider Name (Legal Business Name): KELLY EDWARDS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 05/16/2020
Certification Date: 05/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CATTLEMEN RD
SARASOTA FL
34232-6056
US

IV. Provider business mailing address

11408 GOLDEN BAY PL
LAKEWOOD RANCH FL
34211-3404
US

V. Phone/Fax

Practice location:
  • Phone: 540-597-7021
  • Fax:
Mailing address:
  • Phone: 540-597-7021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024173261
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11007072
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: