Healthcare Provider Details

I. General information

NPI: 1639572647
Provider Name (Legal Business Name): SANDRA KEDDY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2014
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PILLSBURY ST
CONCORD NH
03301-3556
US

IV. Provider business mailing address

4 GREENSBORO RD
HANOVER NH
03755-3100
US

V. Phone/Fax

Practice location:
  • Phone: 603-224-4776
  • Fax:
Mailing address:
  • Phone: 864-505-2454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number039078-21
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number039078-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: