Healthcare Provider Details

I. General information

NPI: 1376887299
Provider Name (Legal Business Name): KELLY L RADFORD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MADISON ST SUITE 306
JOLIET IL
60435-6549
US

IV. Provider business mailing address

PO BOX 936
BEDFORD PARK IL
60499-0936
US

V. Phone/Fax

Practice location:
  • Phone: 708-326-1637
  • Fax:
Mailing address:
  • Phone: 708-326-1637
  • Fax: 708-326-1671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209010013
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: