Healthcare Provider Details

I. General information

NPI: 1396721296
Provider Name (Legal Business Name): ELIZABETH O KELLY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD TRIPLER ARMY MEDICAL CENTER ATTN MCHK-QS
TRIPLER AMC HI
96859-5001
US

IV. Provider business mailing address

94-424 PAWA WAY
MILILANI HI
96789-2607
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-2460
  • Fax:
Mailing address:
  • Phone: 808-623-5897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number44290
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: