Healthcare Provider Details

I. General information

NPI: 1881971224
Provider Name (Legal Business Name): MARYELLE HERNDON KIELY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 ERWIN RD
DURHAM NC
27705-3941
US

IV. Provider business mailing address

5213 S ALSTON AVE
DURHAM NC
27713-4430
US

V. Phone/Fax

Practice location:
  • Phone: 919-620-4917
  • Fax: 919-620-4921
Mailing address:
  • Phone: 919-620-4855
  • Fax: 919-620-4921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number233422
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: