Healthcare Provider Details

I. General information

NPI: 1912272998
Provider Name (Legal Business Name): KELLY LYNN DELESTIENNE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY LYNN TRAX

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 COAL VALLEY RD
CLAIRTON PA
15025-3703
US

IV. Provider business mailing address

565 COAL VALLEY RD
CLAIRTON PA
15025-3703
US

V. Phone/Fax

Practice location:
  • Phone: 412-469-5831
  • Fax: 412-831-5495
Mailing address:
  • Phone: 412-469-5831
  • Fax: 412-831-5495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN597257
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: