Healthcare Provider Details

I. General information

NPI: 1417306838
Provider Name (Legal Business Name): BETHANY A KELLEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY A KING CRNA

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 WORNALL RD
KANSAS CITY MO
64111
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 816-932-3679
  • Fax: 816-932-9089
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number7009-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209021707
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2010026479
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: