Healthcare Provider Details

I. General information

NPI: 1750312633
Provider Name (Legal Business Name): KELLY SUE MCKENZIE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12500 WILLOWBROOK RD WESTERN MD REGIONAL HEALTH SYSTEM
CUMBERLAND MD
21502-6393
US

IV. Provider business mailing address

11321 SNOW LINE DR NW
FROSTBURG MD
21532
US

V. Phone/Fax

Practice location:
  • Phone: 240-964-3306
  • Fax:
Mailing address:
  • Phone: 301-689-0436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number51177
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number049080
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: