Healthcare Provider Details

I. General information

NPI: 1558599837
Provider Name (Legal Business Name): KELLY R O'REILLY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

220 JOHNSTONE DR.
MADISON MS
39110
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5900
  • Fax:
Mailing address:
  • Phone: 601-707-7039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number081436
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: