Healthcare Provider Details

I. General information

NPI: 1134202823
Provider Name (Legal Business Name): MICHELLE A KELLEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 1ST ST
SPRING VALLEY IL
61362-1512
US

IV. Provider business mailing address

2211 TWIN OAK RD
PERU IL
61354-1511
US

V. Phone/Fax

Practice location:
  • Phone: 815-875-6001
  • Fax: 815-875-3612
Mailing address:
  • Phone: 815-224-4241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: