Healthcare Provider Details

I. General information

NPI: 1699757906
Provider Name (Legal Business Name): KELLY CATHERINE DEFEO CRNA , APRN, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 04/08/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 US RTE 302
GLEN NH
03838-6300
US

IV. Provider business mailing address

PO BOX 125
CENTER CONWAY NH
03813-0125
US

V. Phone/Fax

Practice location:
  • Phone: 603-730-5356
  • Fax: 603-730-5477
Mailing address:
  • Phone: 603-730-5356
  • Fax: 603-730-5477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number047170-23-11
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number04717023
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: