Healthcare Provider Details

I. General information

NPI: 1952596751
Provider Name (Legal Business Name): DYNAMIC ANESTHESIA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1564 BROWNFIELD RD
CENTER CONWAY NH
03813
US

IV. Provider business mailing address

1564 BROWNFIELD RD
CENTER CONWAY NH
03813
US

V. Phone/Fax

Practice location:
  • Phone: 603-387-4523
  • Fax: 866-394-0351
Mailing address:
  • Phone: 603-387-4523
  • Fax: 866-394-0351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number04717023-11
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number047170-23-11
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateNH

VIII. Authorized Official

Name: MS. KELLY CATHERINE DEFEO
Title or Position: OWNER
Credential: CRNA, FNP-BC
Phone: 603-387-4523