Healthcare Provider Details

I. General information

NPI: 1003087776
Provider Name (Legal Business Name): THERESA A KELLY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 PARK ST
HONESDALE PA
18431-1445
US

IV. Provider business mailing address

PO BOX 49
PITTSBURGH PA
15230-0049
US

V. Phone/Fax

Practice location:
  • Phone: 570-647-4381
  • Fax:
Mailing address:
  • Phone: 570-647-4381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN298133L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: