Healthcare Provider Details

I. General information

NPI: 1134212236
Provider Name (Legal Business Name): KELLY NELSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MEMORIAL DR
DALTON GA
30720-2529
US

IV. Provider business mailing address

1419 CHATTANOOGA AVE SUITE 4
DALTON GA
30720-2642
US

V. Phone/Fax

Practice location:
  • Phone: 706-259-4435
  • Fax: 706-226-2283
Mailing address:
  • Phone: 706-259-4435
  • Fax: 706-226-2283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN117855
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN117855
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number30340
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: